Provider Demographics
NPI:1932466935
Name:DAVID D.MOON, D.O., LTD
Entity Type:Organization
Organization Name:DAVID D.MOON, D.O., LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:702-876-2225
Mailing Address - Street 1:241 N BUFFALO DR
Mailing Address - Street 2:BLDG. 1
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0306
Mailing Address - Country:US
Mailing Address - Phone:702-876-2225
Mailing Address - Fax:702-876-9307
Practice Address - Street 1:241 N BUFFALO DR
Practice Address - Street 2:BLDG. 1
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0306
Practice Address - Country:US
Practice Address - Phone:702-876-2225
Practice Address - Fax:702-876-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV705207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE993416Medicare UPIN