Provider Demographics
NPI:1659431435
Name:MOON, GABRIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 N WATERMAN AVE
Mailing Address - Street 2:STE 119
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404
Mailing Address - Country:US
Mailing Address - Phone:909-889-8967
Mailing Address - Fax:909-889-8967
Practice Address - Street 1:1455 N WATERMAN AVE
Practice Address - Street 2:STE 119
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-889-8967
Practice Address - Fax:909-889-8967
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000149171100000X
NY003150171100000X
CAAC7117171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22936OtherASHP
AC7117OtherLANDMARK
AC7117OtherLANDMARK