Healthcare Provider Details

I. General information

NPI: 1104876440
Provider Name (Legal Business Name): FREDERICK STEPHEN MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 LIMESTONE OVERLOOK
GAINESVILLE GA
30501-7443
US

IV. Provider business mailing address

PO BOX 907790
GAINESVILLE GA
30501-0912
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-8109
  • Fax: 770-536-3203
Mailing address:
  • Phone: 770-536-8109
  • Fax: 770-536-3203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number022254
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number022254
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number164074
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: