MEDICARE: VICTOR DE MOYA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	53869	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09760	OTHER	FL	BLUE CROSS/BLUE SHIELD FL

General Provider Information

NPI Number	:	1609988112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR DE MOYA M.D.

Provider Business Mailing Address
First Line	:	403A HOLLYWOOD BLVD,, NW
Second Line	:	SUITE 104
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4531
Country	:	US
Telephone Number	:	850-244-0101
Fax Number	:	850-243-9795

Provider Business Practice Location Address
First Line	:	403A HOLLYWOOD BLVD,, NW
Second Line	:	SUITE 104
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4531
Country	:	US
Telephone Number	:	850-244-0101
Fax Number	:	850-243-9795

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	04/05/2012

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