MEDICARE: DR. DAVID W MOON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9839	SC

General Provider Information

NPI Number	:	1417053133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID W MOON M.D.

Provider Business Mailing Address
First Line	:	276 N RON MCNAIR BLVD
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2462
Country	:	US
Telephone Number	:	843-394-5471
Fax Number	:	843-394-5459

Provider Business Practice Location Address
First Line	:	276 N RON MCNAIR BLVD
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2462
Country	:	US
Telephone Number	:	843-394-5471
Fax Number	:	843-394-5459

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	05/15/2014

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