Healthcare Provider Details

I. General information

NPI: 1255406898
Provider Name (Legal Business Name): JUSTIN RANDOLPH MOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD STE 301
JACKSONVILLE FL
32258-5472
US

IV. Provider business mailing address

PO BOX 41516
JACKSONVILLE FL
32203-1516
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-6410
  • Fax: 904-390-7382
Mailing address:
  • Phone: 904-202-5111
  • Fax: 904-391-5836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number13287
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01061468A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME128553
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: