Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | ME141155 | FL |
N | 207YX0007X | Plastic Surgeon (Head & Neck) | ME141155 | FL |
NPI | 1164867644 |
---|---|
Provider Name | Joseph Samuel Moak III |
First Address | Leesburg, FL 34748-5998 |
Second Address | Tavares, FL 32778-4311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2013 |
Last Update Date | 02/07/2019 |