Basic Information
| Provider Information | |||||||||
| NPI: | 1447468236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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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 | 208600000X | 4301077667 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 244628 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | A104905 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | AS352 | 01 | CA | MEDICARE NUMBER | OTHER |