Provider Demographics
NPI:1396735908
Name:MORAN, ANTONIO JR (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:MORAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:1111 GLYNCO PKWY STE 35
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7930
Practice Address - Country:US
Practice Address - Phone:912-304-7013
Practice Address - Fax:912-342-1025
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA34669207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA028147OtherBCBS
GA00471248HMedicaid
GAE41967Medicare UPIN
511G700649Medicare PIN