Provider Demographics
NPI:1215957832
Name:MOON, TIMOTHY W (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:MOON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:445 FACTORY ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2729
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:173 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1510
Practice Address - Country:US
Practice Address - Phone:315-287-3285
Practice Address - Fax:315-287-3280
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB4944Medicare PIN
NYH79904Medicare UPIN