Healthcare Provider Details

I. General information

NPI: 1194769661
Provider Name (Legal Business Name): PAUL DOUGLAS MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N MAIN ST STE 100
FOUNTAIN INN SC
29644-1320
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-967-4982
  • Fax:
Mailing address:
  • Phone: 864-797-6174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23342
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: