Healthcare Provider Details

I. General information

NPI: 1437113651
Provider Name (Legal Business Name): LESLIE JARROTT MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 TAYLOR ST STE 5F
COLUMBIA SC
29201-2951
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-748-9966
  • Fax: 803-748-7174
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32261
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number32261
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: