Basic Information
| Provider Information | |||||||||
| NPI: | 1518978881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORMAN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 OLD OCILLA RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293862181 | ||||||||
| FaxNumber: | 2293862193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1803 OLD OCILLA RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293862181 | ||||||||
| FaxNumber: | 2293862193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 014938 | GA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 000018334A4 | 05 | GA | MEDICAID |