Provider Demographics
NPI:1609882133
Name:MOON, ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:MOON
Suffix:
Gender:M
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 398398
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-8398
Mailing Address - Country:US
Mailing Address - Phone:888-991-1101
Mailing Address - Fax:903-787-5854
Practice Address - Street 1:3875 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2428
Practice Address - Country:US
Practice Address - Phone:510-547-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65483207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A654830Medicaid
CA00A654830Medicaid
00A654830Medicare ID - Type Unspecified
CA00A654832Medicare PIN