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General NPI Number Information
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NPI Number | 1194970475
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Entity Type | Individual
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Provider Name | MOSES DESMOND DEGRAFT-JOHNSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/30/2008
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Last Update Date | 05/18/2017
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Provider Practice Location Address
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Address Line | 2623 CENTENNIAL BLVD SUITE 102
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City | TALLAHASSEE
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State | FL
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Zip | 32308-0585
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Country | US
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Telephone | 850-792-4722
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Fax | 850-792-4727
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Provider Business Mailing Address
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Address Line | 400 CAPITAL CIR SE STE 18148
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City | TALLAHASSEE
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State | FL
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Zip | 32301-3802
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Country | US
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Telephone | 850-792-4722
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Fax | 850-792-4727
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | ME106359
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License Number State | FL
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