Provider Demographics
NPI:1417913526
Name:MOON, LEAH NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:NICOLE
Last Name:MOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 1F
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3365
Practice Address - Country:US
Practice Address - Phone:423-857-2793
Practice Address - Fax:423-578-8025
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37074207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN38798571Medicaid
TN4106588OtherBCBS
KY7100019690Medicaid
TNTN01U8OtherJOHN DEERE
TN3879857Medicaid
TN3879857Medicaid
TN4106588OtherBCBS
H74913Medicare UPIN
TN38798571Medicaid
TNP00640965Medicare PIN
TN3879851Medicare PIN