Healthcare Provider Details

I. General information

NPI: 1376544577
Provider Name (Legal Business Name): KARL E.T. MOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10815 W. MCDOWELL RD. STE 202
AVONDALE AZ
85392-5007
US

IV. Provider business mailing address

9250 N 3RD ST STE 4010
PHOENIX AZ
85020-2437
US

V. Phone/Fax

Practice location:
  • Phone: 623-433-0202
  • Fax: 623-433-0204
Mailing address:
  • Phone: 602-633-3848
  • Fax: 602-633-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25645
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: