=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619491446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOON MD INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 08/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5959 TRUXTUN AVE
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93309-0435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-638-0601
-----------------------------------------------------
Fax | 661-638-0606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 81198
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93380-1198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-638-0601
-----------------------------------------------------
Fax | 661-638-0606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CYRUS R MOON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 661-638-0601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A106616
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------