Provider Demographics
NPI:1457368920
Name:MOON, CARL RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RICHARD
Last Name:MOON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 DALE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MN
Mailing Address - Zip Code:56374-9451
Mailing Address - Country:US
Mailing Address - Phone:320-363-4226
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-255-6429
Practice Address - Fax:320-255-6406
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2001152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist