Healthcare Provider Details

I. General information

NPI: 1750358305
Provider Name (Legal Business Name): RICHARD LEROY MOONEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W
RANDOLPH A F B TX
78150-4800
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-8544
  • Fax: 210-652-9836
Mailing address:
  • Phone: 757-594-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: