Healthcare Provider Details

I. General information

NPI: 1942859483
Provider Name (Legal Business Name): DAVID CARSON MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2019
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 VILLAGE CREEK DR
BOILING SPRINGS SC
29316-5387
US

IV. Provider business mailing address

316 VILLAGE CREEK DR
BOILING SPRINGS SC
29316-5387
US

V. Phone/Fax

Practice location:
  • Phone: 864-327-9003
  • Fax:
Mailing address:
  • Phone: 864-327-9003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberMPA3438
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMPA3438
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMPA3438
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: