Provider Demographics
NPI:1396064804
Name:MOORE, DOUGLAS BOYLSTON III (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BOYLSTON
Last Name:MOORE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TREY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:901 W GREENWOOD ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-5717
Mailing Address - Country:US
Mailing Address - Phone:864-366-9681
Mailing Address - Fax:864-366-5600
Practice Address - Street 1:901 W GREENWOOD ST
Practice Address - Street 2:SUITE 9
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5717
Practice Address - Country:US
Practice Address - Phone:864-366-9681
Practice Address - Fax:864-366-5600
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC326347Medicaid
SCPC3126Medicaid
SCRHC210Medicaid
SC3255Medicare PIN
SCRHC210Medicaid