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General NPI Number Information
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NPI Number | 1487712295
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Entity Type | Individual
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Provider Name | CHARLES M. MOON MD
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Gender | Male
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 01/31/2017
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Provider Practice Location Address
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Address Line | 1359 N MOUNT AUBURN RD
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City | CAPE GIRARDEAU
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State | MO
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Zip | 63701-1727
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Country | US
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Telephone | 573-335-7546
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Fax | 573-335-7550
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Provider Business Mailing Address
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Address Line | 2116 MEGAN DR STE 102
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City | CAPE GIRARDEAU
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State | MO
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Zip | 63701-1979
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Country | US
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Telephone | 573-335-7546
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Fax | 573-335-7550
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 01053751A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 2007038037
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License Number State | MO
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