Provider Demographics
NPI:1699700732
Name:MOON, CHRISTOPHER S (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
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 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-1125
Mailing Address - Country:US
Mailing Address - Phone:804-798-8307
Mailing Address - Fax:804-798-4204
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1125
Practice Address - Country:US
Practice Address - Phone:804-798-8307
Practice Address - Fax:804-798-4204
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10290945Medicaid
VA10290945Medicaid
VA012036V33Medicare PIN