Provider Demographics
NPI:1255366035
Name:MOON, KELLEY E (MD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:E
Last Name:MOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4269
Mailing Address - Country:US
Mailing Address - Phone:936-564-7206
Mailing Address - Fax:
Practice Address - Street 1:1320 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4269
Practice Address - Country:US
Practice Address - Phone:936-564-7206
Practice Address - Fax:936-559-9701
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4067261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH32948Medicare UPIN
TX00939FMedicare ID - Type Unspecified