Provider Demographics
NPI:1396953105
Name:MOON, ALFRED (MD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:MOON
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 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:4300 ROSE DR
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-2026
Practice Address - Country:US
Practice Address - Phone:714-528-4211
Practice Address - Fax:714-579-6868
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186653207R00000X
CAA104707207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACM196WMedicare PIN