Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208800000X | Urologist | 19690 | FL |
Y | 208800000X | Urologist | 26534 | MS |
N | 208800000X | Urologist | ME124782 | FL |
NPI | 1063824688 |
---|---|
Provider Name | John Moore |
First Address | Hattiesburg, MS 39401-7246 |
Second Address | Hattiesburg, MS 39401-7246 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2014 |
Last Update Date | 08/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04421823 | (05) | MS |