MEDICARE: DR. JERRY A MOON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2250	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71078816172543	OTHER		TRICARE
2	2220019	OTHER		UNITED HEALTH

General Provider Information

NPI Number	:	1427049147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY A MOON O.D.

Provider Business Mailing Address
First Line	:	PO BOX 2
Second Line	:	509 N SECOND STREET
City	:	HEBER SPRINGS
State	:	AR
Zip	:	72543-0002
Country	:	US
Telephone Number	:	501-362-8191
Fax Number	:	501-362-3096

Provider Business Practice Location Address
First Line	:	509 N 2ND ST
Second Line	:
City	:	HEBER SPRINGS
State	:	AR
Zip	:	72543-2513
Country	:	US
Telephone Number	:	501-362-8191
Fax Number	:	501-362-3096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	04/17/2008

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