Healthcare Provider Details

I. General information

NPI: 1013274158
Provider Name (Legal Business Name): JOHN HARTWELL HOUSTON MOONEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S 18TH ST STE 202
FERNANDINA BEACH FL
32034-4729
US

IV. Provider business mailing address

PO BOX 746652
ATLANTA GA
30374-6652
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-9786
  • Fax: 904-376-3203
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME136011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: