Provider Demographics
NPI:1619014230
Name:MOON, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
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 1:5348 CARROLL CANYON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1733
Mailing Address - Country:US
Mailing Address - Phone:858-202-1546
Mailing Address - Fax:858-202-1548
Practice Address - Street 1:5348 CARROLL CANYON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1733
Practice Address - Country:US
Practice Address - Phone:858-202-1546
Practice Address - Fax:858-202-1548
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61865208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0096070Medicaid
CAZZZ07215ZOtherBLUE SHIELD
CAA61865OtherLICENSE NUMBER
CA127169100OtherACS-US DEPT OF LABOR
CA330992123OtherBLUE CROSS
CAP00302519OtherRAIL ROAD MEDICARE
CA127169100OtherACS-US DEPT OF LABOR
CAP00302519OtherRAIL ROAD MEDICARE
CAH16826Medicare UPIN