Provider Demographics
NPI:1558393975
Name:MOON, STEPHEN L (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:MOON
Suffix:
Gender:M
Credentials:OD
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 1112
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-1112
Mailing Address - Country:US
Mailing Address - Phone:304-366-0700
Mailing Address - Fax:304-367-8766
Practice Address - Street 1:1322 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1436
Practice Address - Country:US
Practice Address - Phone:304-366-0700
Practice Address - Fax:304-367-8766
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV783D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV227498OtherOPTIMUM CHOICE
WVV27522OtherWV WORKER'S COMP
WV505817OtherNATIONAL CAPITAL PPO
WV001718661OtherMT STATE BC/BS
WV0004613017OtherAETNA
WV0150898000Medicaid
WV410025059OtherRR MEDICARE
WVFQ783OtherHEALTH PLAN
WV0150898000Medicaid
WVMO0647251Medicare PIN