Healthcare Provider Details

I. General information

NPI: 1790738912
Provider Name (Legal Business Name): RICHARD CARL MOONEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W COUNTRY CLUB RD
ROSWELL NM
88201-5892
US

IV. Provider business mailing address

PO BOX 2608
ROSWELL NM
88202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6322
  • Fax: 575-622-6888
Mailing address:
  • Phone: 575-622-6322
  • Fax: 575-622-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number85-73
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: