Basic Information
| Provider Information | |||||||||
| NPI: | 1376544577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | KARL | ||||||||
| MiddleName: | E.T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9250 N 3RD ST | ||||||||
| Address2: | STE 4010 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333848 | ||||||||
| FaxNumber: | 6026333841 | ||||||||
| Practice Location | |||||||||
| Address1: | 10815 W. MCDOWELL RD. | ||||||||
| Address2: | STE 202 | ||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853925007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234330202 | ||||||||
| FaxNumber: | 6234330204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 25645 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 394734 | 05 | AZ | MEDICAID |