Healthcare Provider Details

I. General information

NPI: 1366421398
Provider Name (Legal Business Name): US NAVAL HOSPITAL ROTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 819 BOX 18-312
FPO AE
09645
US

IV. Provider business mailing address

PSC 819 BOX 18-312
FPO AE
09645
US

V. Phone/Fax

Practice location:
  • Phone: 956828904
  • Fax:
Mailing address:
  • Phone: 956828904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberA74239
License Number StateCA

VIII. Authorized Official

Name: DR. WON K MOON
Title or Position: STAFF FAMILY MEDICINE
Credential: M.D.
Phone: 349-568-2890