Healthcare Provider Details

I. General information

NPI: 1013024330
Provider Name (Legal Business Name): TODD STANLEY MOONEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 200 N
PANGUITCH UT
84759-0389
US

IV. Provider business mailing address

PO BOX 389
PANGUITCH UT
84759-0389
US

V. Phone/Fax

Practice location:
  • Phone: 435-676-8811
  • Fax: 435-676-2679
Mailing address:
  • Phone: 435-676-8811
  • Fax: 435-676-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30991171205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: