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: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11082 N RADIO STATION RD
SENECA SC
29678-1142
US

IV. Provider business mailing address

300 E MCBEE AVE STE 300
GREENVILLE SC
29601-2899
US

V. Phone/Fax

Practice location:
  • Phone: 864-882-2314
  • Fax: 864-882-3677
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40702
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: