MEDICARE: DR. MOON IP 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	208600000X	Surgery Physician	A35407	CA

General Provider Information

NPI Number	:	1588062566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOON IP MD

Provider Business Mailing Address
First Line	:	4300 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4902
Country	:	US
Telephone Number	:	323-298-1000
Fax Number	:	323-298-0458

Provider Business Practice Location Address
First Line	:	4300 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4902
Country	:	US
Telephone Number	:	323-298-1000
Fax Number	:	323-298-0458

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

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	12/08/2014

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