Provider Demographics
NPI:1649546284
Name:MOON, JARED L (DPM)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:L
Last Name:MOON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10607 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7504
Mailing Address - Country:US
Mailing Address - Phone:262-366-7994
Mailing Address - Fax:
Practice Address - Street 1:10607 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7504
Practice Address - Country:US
Practice Address - Phone:262-366-7994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001156213E00000X
IN99053018A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1922201227Medicare PIN