Healthcare Provider Details

I. General information

NPI: 1871516930
Provider Name (Legal Business Name): DEREK RONALD MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 JESSE JEWELL PKWY SE STE B
GAINESVILLE GA
30501-3854
US

IV. Provider business mailing address

PO BOX 658
GAINESVILLE GA
30503-0658
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-7092
  • Fax: 770-536-0383
Mailing address:
  • Phone: 770-718-1122
  • Fax: 770-535-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number054090
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: