Healthcare Provider Details

I. General information

NPI: 1982636742
Provider Name (Legal Business Name): RODERICK DONALD MOE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16723 HUEBNER RD
SAN ANTONIO TX
78248-2342
US

IV. Provider business mailing address

903 W MARTIN ST # MS 49-2
SAN ANTONIO TX
78207-0903
US

V. Phone/Fax

Practice location:
  • Phone: 210-733-4368
  • Fax: 210-402-3417
Mailing address:
  • Phone: 210-358-0572
  • Fax: 210-358-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberF9837
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberF9837
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: