Basic Information
| Provider Information | |||||||||
| NPI: | 1104147909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | KARAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1331 N 7TH ST | ||||||||
| Address2: | STE 275 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022543151 | ||||||||
| FaxNumber: | 6022569581 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W THOMAS RD | ||||||||
| Address2: | ATTN: ACADEMIC AFFAIRS | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063000 | ||||||||
| FaxNumber: | 6022948286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2010 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | R72004 | AZ | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | R72004 | 01 | AZ | AZ TRAINING PERMIT | OTHER |