MEDICARE: DR. CHARLES M. MOON MD

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	207N00000X	Dermatology Physician	01053751A	IN
2	207N00000X	Dermatology Physician	2007038037	MO

General Provider Information

NPI Number	:	1487712295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES M. MOON MD

Provider Business Mailing Address
First Line	:	2116 MEGAN DR
Second Line	:	STE 102
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-1979
Country	:	US
Telephone Number	:	573-335-7546
Fax Number	:	573-335-7550

Provider Business Practice Location Address
First Line	:	1359 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-1727
Country	:	US
Telephone Number	:	573-335-7546
Fax Number	:	573-335-7550

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	01/31/2017

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Directions to “ DR. CHARLES M. MOON MD” Practice Location

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