Basic Information
| Provider Information | |||||||||
| NPI: | 1871516930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | RONALD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 JESSE JEWELL PKWY SE | ||||||||
| Address2: | STE B | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705327092 | ||||||||
| FaxNumber: | 7705360383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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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 | 207X00000X | 054090 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0901538 | 01 | GA | UHC | OTHER | 10062471 | 01 | GA | AMERIGROUP | OTHER | 203604041D | 05 | GA | MEDICAID | 7851732 | 01 | GA | AETNA | OTHER | 52703247 | 01 | GA | BCBS | OTHER | 203604041C | 05 | GA | MEDICAID | 4599810 | 01 | GA | CIGNA | OTHER | P00349858 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER | 342650 | 01 | GA | WELLCARE | OTHER |