Provider Demographics
NPI:1255357778
Name:MOOTH, DAVID CARROLL (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:CARROLL
Last Name:MOOTH
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 1:9360 BRINKMAN RD
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-3263
Mailing Address - Country:US
Mailing Address - Phone:618-594-2329
Mailing Address - Fax:
Practice Address - Street 1:9360 BRINKMAN RD
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-3263
Practice Address - Country:US
Practice Address - Phone:618-594-2329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093809207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00294Medicare PIN
ILG63900Medicare UPIN