Provider Demographics
NPI:1316272180
Name:MULDOON, BECKY THAI (MD)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:THAI
Last Name:MULDOON
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 1:100 E VALENCIA MESA DR STE 105
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3816
Mailing Address - Country:US
Mailing Address - Phone:714-446-5640
Mailing Address - Fax:
Practice Address - Street 1:100 E VALENCIA MESA DR STE 105
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3816
Practice Address - Country:US
Practice Address - Phone:714-446-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD16114207RE0101X
CAC172133207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN