Provider Demographics
NPI:1306387337
Name:MOONEY, JOHN (CPO1410)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MOONEY
Suffix:
Gender:M
Credentials:CPO1410
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 W KENBOERN DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1835
Mailing Address - Country:US
Mailing Address - Phone:414-540-1202
Mailing Address - Fax:
Practice Address - Street 1:2555 W KENBOERN DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-1835
Practice Address - Country:US
Practice Address - Phone:414-540-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist