Healthcare Provider Details

I. General information

NPI: 1720140536
Provider Name (Legal Business Name): DOUGLAS PAUL MOARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W5282 AMY AVE
APPLETON WI
54915-7233
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-358-1900
  • Fax: 920-358-1909
Mailing address:
  • Phone: 920-996-3298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26838-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26838
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: