Provider Demographics
NPI:1194769661
Name:MOORE, PAUL DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DOUGLAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6174
Mailing Address - Fax:
Practice Address - Street 1:910 N MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1320
Practice Address - Country:US
Practice Address - Phone:864-967-4982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4591406OtherAETNA ID
SCF394375453Medicare PIN
SC4591406OtherAETNA ID