Provider Demographics
NPI:1457576167
Name:MOONFIELD MEDICAL MGMT. CORP
Entity type:Organization
Organization Name:MOONFIELD MEDICAL MGMT. CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOON
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-734-7600
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-1269
Mailing Address - Country:US
Mailing Address - Phone:951-734-7600
Mailing Address - Fax:951-734-1557
Practice Address - Street 1:710 E PARKRIDGE AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1097
Practice Address - Country:US
Practice Address - Phone:951-734-7600
Practice Address - Fax:951-734-1557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA032377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A323770Medicaid
CA00A323770Medicaid