Healthcare Provider Details

I. General information

NPI: 1366431983
Provider Name (Legal Business Name): GUY RUDOLPH MOISE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 NW 120TH ST
NORTH MIAMI FL
33168-2529
US

IV. Provider business mailing address

650 NW 120TH ST
NORTH MIAMI FL
33168-2529
US

V. Phone/Fax

Practice location:
  • Phone: 305-688-0811
  • Fax: 305-687-5831
Mailing address:
  • Phone: 305-688-0811
  • Fax: 305-687-5831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS4440
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS 0004440
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: