Provider Demographics
NPI:1235287004
Name:MOOGERFELD, BRIAN A (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:MOOGERFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1088A BERMUDA RUN
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0858
Mailing Address - Country:US
Mailing Address - Phone:912-681-7111
Mailing Address - Fax:912-871-7794
Practice Address - Street 1:1088A BERMUDA RUN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0858
Practice Address - Country:US
Practice Address - Phone:912-681-7111
Practice Address - Fax:912-871-7794
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051598207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA594331017BMedicaid
GA594331017AMedicaid
GA11BDVRJMedicare PIN
GA594331017BMedicaid