Provider Demographics
NPI:1154558732
Name:MOY, CALVIN (MD)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:MOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9674
Mailing Address - Country:US
Mailing Address - Phone:815-844-6123
Mailing Address - Fax:815-884-7851
Practice Address - Street 1:1506 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9674
Practice Address - Country:US
Practice Address - Phone:815-844-6123
Practice Address - Fax:815-884-7851
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125057045390200000X
IL036-128985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program