Provider Demographics
NPI:1871516930
Name:MOORE, DEREK RONALD (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:RONALD
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:STE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:770-532-7092
Practice Address - Fax:770-536-0383
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054090207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0901538OtherUHC
GA10062471OtherAMERIGROUP
GA203604041DMedicaid
GA7851732OtherAETNA
GA52703247OtherBCBS
GA203604041CMedicaid
GA4599810OtherCIGNA
GAP00349858OtherRR MEDICARE-GRP # CC4177
GA342650OtherWELLCARE
GA203604041CMedicaid
GA4599810OtherCIGNA