Healthcare Provider Details

I. General information

NPI: 1013131598
Provider Name (Legal Business Name): ROBERT WAYNE MOONEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 JONES MILL RD
STATESBORO GA
30458-4765
US

IV. Provider business mailing address

311 JONES MILL RD
STATESBORO GA
30458-4765
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-6236
  • Fax: 912-764-7063
Mailing address:
  • Phone: 912-764-6236
  • Fax: 912-764-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number036828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: