Provider Demographics
NPI:1154376101
Name:MOON, RENATA MILENA STOSZEK (MD)
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:MILENA STOSZEK
Last Name:MOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1402
Mailing Address - Country:US
Mailing Address - Phone:877-336-6077
Mailing Address - Fax:
Practice Address - Street 1:322 W NORTH RIVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3208
Practice Address - Country:US
Practice Address - Phone:509-324-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME154557208000000X
WAMD00043974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB32999OtherMEDICARE GROUP
WA8402687Medicaid
WA8850930Medicare PIN
WAG47680Medicare UPIN
WAG8859849Medicare PIN