Basic Information
| Provider Information | |||||||||
| NPI: | 1295772507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 WHITE ALDER AVE | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919142611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195039000 | ||||||||
| FaxNumber: | 7145628729 | ||||||||
| Practice Location | |||||||||
| Address1: | 7212 ORANGETHORPE AVE | ||||||||
| Address2: | SUITE 9A | ||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906213341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145036550 | ||||||||
| FaxNumber: | 7145628729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | A76947 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A769470 | 05 | CA | MEDICAID |