Healthcare Provider Details

I. General information

NPI: 1215957832
Provider Name (Legal Business Name): TIMOTHY W MOON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 E MAIN ST
GOUVERNEUR NY
13642-1510
US

IV. Provider business mailing address

445 FACTORY ST
WATERTOWN NY
13601-2729
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-3285
  • Fax: 315-287-3280
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number224227
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: