Provider Demographics
NPI:1790124691
Name:MOONEY, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:60 FENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6128
Mailing Address - Country:US
Mailing Address - Phone:248-933-0570
Mailing Address - Fax:602-294-8286
Practice Address - Street 1:60 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6128
Practice Address - Country:US
Practice Address - Phone:248-933-0570
Practice Address - Fax:602-294-8286
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMCS004591A207T00000X
MA281414207T00000X
MA284117207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR74142OtherAZ TRAINING PERMIT