Healthcare Provider Details

I. General information

NPI: 1932466935
Provider Name (Legal Business Name): DAVID D.MOON, D.O., LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 N BUFFALO DR BLDG. 1
LAS VEGAS NV
89145-0306
US

IV. Provider business mailing address

241 N BUFFALO DR BLDG. 1
LAS VEGAS NV
89145-0306
US

V. Phone/Fax

Practice location:
  • Phone: 702-876-2225
  • Fax: 702-876-9307
Mailing address:
  • Phone: 702-876-2225
  • Fax: 702-876-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number705
License Number StateNV

VIII. Authorized Official

Name: DR. DAVID DEWAYNE MOON
Title or Position: OWNER
Credential: D.O.
Phone: 702-876-2225