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General NPI Number Information
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NPI Number | 1447847975
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Entity Type | Organization
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Legal Business Name | CALLISTO PEDIATRICS, PLLC
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Dates
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Enumeration Date | 12/30/2020
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Last Update Date | 12/30/2020
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Provider Practice Location Address
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Address Line | 320 SEAGLE STREET SUITE#10
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City | HUNTERSVILLE
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State | NC
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Zip | 28078
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Country | US
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Telephone | 704-368-4351
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Fax |
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Provider Business Mailing Address
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Address Line | 145 TOWN LOOP APT B107
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City | MOORESVILLE
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State | NC
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Zip | 28117-0020
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Country | US
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Telephone | 513-225-8170
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TARA MOON
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Credential | MD
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Telephone | 513-225-8170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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