Healthcare Provider Details

I. General information

NPI: 1952411779
Provider Name (Legal Business Name): DAVID C MOE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC RADIOLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC RADIOLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2523
  • Fax: 414-266-1525
Mailing address:
  • Phone: 414-266-2523
  • Fax: 414-266-1525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD00046543
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number47272
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: