Basic Information
| Provider Information | |||||||||
| NPI: | 1437113883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | HERBERT | ||||||||
| MiddleName: | SLOCUM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 WELLINGTON AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | GRAND JCT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815016131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702438812 | ||||||||
| FaxNumber: | 9702411308 | ||||||||
| Practice Location | |||||||||
| Address1: | 2635 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JCT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815018209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702442070 | ||||||||
| FaxNumber: | 9702411308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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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 | 207ZP0102X | 32351 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | T0160 | 05 | UT | MEDICAID | 01323518 | 05 | CO | MEDICAID |