Provider Demographics
NPI:1780020529
Name:MOON, SAVANNAH (DO)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 SE 2ND ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3639
Mailing Address - Country:US
Mailing Address - Phone:954-328-1602
Mailing Address - Fax:
Practice Address - Street 1:717 SE 2ND ST STE 100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3639
Practice Address - Country:US
Practice Address - Phone:954-707-5158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN18792208600000X
FLOS162092086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery