Basic Information
| Provider Information | |||||||||
| NPI: | 1356428148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULDOON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788300 | ||||||||
| FaxNumber: | 8582781708 | ||||||||
| Practice Location | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788300 | ||||||||
| FaxNumber: | 8582781708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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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 | 207X00000X | G70877 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | G70877 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G708770 | 05 | CA | MEDICAID |