Healthcare Provider Details

I. General information

NPI: 1831541861
Provider Name (Legal Business Name): ANOOSH MOIN M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 10/18/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

2317 NW 187TH TER
EDMOND OK
73012-7688
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8001
  • Fax:
Mailing address:
  • Phone: 847-429-8687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number39109
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.069288
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: