Basic Information
Provider Information
NPI: 1003018342
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MOON
FirstName: BRIAN
MiddleName: BISHOP
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3599 UNIVERSITY BLVD. S.
Address2: BLDG. 300
City: JACKSONVILLE
State: FL
PostalCode: 32216
CountryCode: US
TelephoneNumber: 8048289783
FaxNumber:  
Practice Location
Address1: 3599 UNIVERSITY BLVD. S.
Address2: BLDG. 300
City: JACKSONVILLE
State: FL
PostalCode: 32216
CountryCode: US
TelephoneNumber: 9043995550
FaxNumber: 9043464334
Other Information
ProviderEnumerationDate: 05/31/2007
LastUpdateDate: 08/22/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0202XME115592FLY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
2085R0204XME115592FLN Allopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology

No ID Information.


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