Provider Demographics
NPI:1972651941
Name:MOON, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
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 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 770
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-871-3280
Mailing Address - Fax:
Practice Address - Street 1:94 GREAT LAWN
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-3423
Practice Address - Country:US
Practice Address - Phone:949-786-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A811560Medicaid
I24491Medicare UPIN