Healthcare Provider Details

I. General information

NPI: 1174635601
Provider Name (Legal Business Name): DURMAN WILLIAM MOOSE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 ABBEY PL STE 105
CHARLOTTE NC
28209-3835
US

IV. Provider business mailing address

PO BOX 78030
CHARLOTTE NC
28271-7023
US

V. Phone/Fax

Practice location:
  • Phone: 704-512-5360
  • Fax: 704-512-5080
Mailing address:
  • Phone: 704-458-9431
  • Fax: 704-844-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32543
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number32543
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: