Provider Demographics
NPI:1629023387
Name:MICHAEL MOON MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL MOON MD A MEDICAL CORPORATION
Other - Org Name:PAINCARE OF SAN DIEGO, AMC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-202-1546
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA618652081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR009670Medicaid
CA127169100OtherUS DEPARTMENT OF LABOR
CAZZZ07215ZOtherBLUE SHIELD
CAZZZ07215ZOtherBLUE SHIELD
CAGR009670Medicaid