MEDICARE: DAVID MOON

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1821246802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID MOON

Provider Business Mailing Address
First Line	:	1619 RIVER DR
Second Line	:
City	:	HAMMOND
State	:	IN
Zip	:	46324-3342
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1619 RIVER DR
Second Line	:
City	:	HAMMOND
State	:	IN
Zip	:	46324-3342
Country	:	US
Telephone Number	:	219-513-8484
Fax Number	:

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

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	09/03/2008

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Directions to “ DAVID MOON ” Practice Location

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