Provider Demographics
NPI:1538175641
Name:MOORE, JAMES LEWIS (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LEWIS
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:740 PRINCE AVE
Mailing Address - Street 2:BLDG 10
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5908
Mailing Address - Country:US
Mailing Address - Phone:706-850-3603
Mailing Address - Fax:706-850-8856
Practice Address - Street 1:740 PRINCE AVE
Practice Address - Street 2:BLDG 10
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5908
Practice Address - Country:US
Practice Address - Phone:706-850-3603
Practice Address - Fax:706-850-8856
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA021556208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46184Medicare UPIN
GA24BCBRPMedicare ID - Type Unspecified
GA00199405DMedicaid