Healthcare Provider Details

I. General information

NPI: 1902003841
Provider Name (Legal Business Name): CHARLES B MOOMEY JR MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DRIVE SUITE 300
LAWRENCEVILLE GA
30046-3371
US

IV. Provider business mailing address

631 PROFESSIONAL DRIVE SUITE 300
LAWRENCEVILLE GA
30046-3371
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-9977
  • Fax: 770-339-9804
Mailing address:
  • Phone: 770-962-9977
  • Fax: 770-339-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number049923
License Number StateGA

VIII. Authorized Official

Name: CHARLES BRUCE MOOMEY JR.
Title or Position: OWNER
Credential: M.D.
Phone: 770-962-9977