Basic Information
| Provider Information | |||||||||
| NPI: | 1952411779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC RADIOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662523 | ||||||||
| FaxNumber: | 4142661525 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC RADIOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662523 | ||||||||
| FaxNumber: | 4142661525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | MD00046543 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 47272 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1952411779 | 05 | WI | MEDICAID |