Provider Demographics
NPI:1831430370
Name:FULL MOON PHYSICIAN, LLLP
Entity type:Organization
Organization Name:FULL MOON PHYSICIAN, LLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, FULL MOON PHYSICIAN MGT
Authorized Official - Prefix:DR
Authorized Official - First Name:GIANG
Authorized Official - Middle Name:LUONG
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-829-3999
Mailing Address - Street 1:2430 FRY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-5831
Mailing Address - Country:US
Mailing Address - Phone:281-829-3999
Mailing Address - Fax:281-829-5146
Practice Address - Street 1:2430 FRY RD
Practice Address - Street 2:STE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5831
Practice Address - Country:US
Practice Address - Phone:281-829-3999
Practice Address - Fax:281-829-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9440261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty