=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730383423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT CLARK MOOTY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 03/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10105 QUAKER AVENUE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79423-7380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-797-6398
-----------------------------------------------------
Fax | 806-797-6399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10105 QUAKER AVENUE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79423-7380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-797-6398
-----------------------------------------------------
Fax | 806-797-6399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | N0288
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------