Provider Demographics
NPI:1609985647
Name:MOONEY, MICHAEL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MOONEY
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 1:2211 E MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4329
Mailing Address - Country:US
Mailing Address - Phone:360-619-4270
Mailing Address - Fax:
Practice Address - Street 1:2211 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4329
Practice Address - Country:US
Practice Address - Phone:360-619-4270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043433208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G55958Medicare UPIN
02BDHVBMedicare ID - Type Unspecified