Healthcare Provider Details

I. General information

NPI: 1801896980
Provider Name (Legal Business Name): ROBERT H MOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 SAINT LUKES DR MONTGOMERY EAST FAMILY PRACTICE PC
MONTGOMERY AL
36117-7109
US

IV. Provider business mailing address

309 SAINT LUKES DR MONTGOMERY EAST FAMILY PRACTICE PC
MONTGOMERY AL
36117-7109
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-0066
  • Fax: 334-272-5015
Mailing address:
  • Phone: 334-272-0066
  • Fax: 334-272-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15530
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: