=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427049147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY A MOON O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2005
-----------------------------------------------------
Last Update Date | 04/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 N 2ND ST
-----------------------------------------------------
City | HEBER SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72543-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-362-8191
-----------------------------------------------------
Fax | 501-362-3096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2 509 N SECOND STREET
-----------------------------------------------------
City | HEBER SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72543-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-362-8191
-----------------------------------------------------
Fax | 501-362-3096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2250
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------