MEDICARE: SUSAN M. 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	M3330	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1598771610	OTHER	TX	NPI

General Provider Information

NPI Number	:	1598771610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M. MOON M.D.

Provider Business Mailing Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-4504
Country	:	US
Telephone Number	:	210-295-8239
Fax Number	:	210-295-8061

Provider Business Practice Location Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-6200
Country	:	US
Telephone Number	:	210-295-8239
Fax Number	:	210-295-8061

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	09/05/2014

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