Provider Demographics
NPI:1881952828
Name:MOON, ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 KATELLA AVENUE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720
Mailing Address - Country:US
Mailing Address - Phone:562-789-3888
Mailing Address - Fax:562-799-3880
Practice Address - Street 1:3851 KATELLA AVENUE
Practice Address - Street 2:SUITE 301
Practice Address - City:LAS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720
Practice Address - Country:US
Practice Address - Phone:562-789-3888
Practice Address - Fax:562-799-3880
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA143260207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program