Provider Demographics
NPI:1306042254
Name:MOISTER, BRENT (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MOISTER
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 1:24 MEMORIAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4452
Mailing Address - Country:US
Mailing Address - Phone:864-697-2009
Mailing Address - Fax:
Practice Address - Street 1:24 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-697-2009
Practice Address - Fax:864-697-2009
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070181042086S0122X
SC361402086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery