Provider Demographics
NPI:1679542781
Name:MOSS, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MOSS
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 1:814 NORTHWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1398
Mailing Address - Country:US
Mailing Address - Phone:229-259-0032
Mailing Address - Fax:229-259-0068
Practice Address - Street 1:814 NORTHWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1398
Practice Address - Country:US
Practice Address - Phone:229-259-0032
Practice Address - Fax:229-259-0068
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41178207P00000X
FLME58453207P00000X
NY1870621207P00000X
GA041178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687574KMedicaid
110177668OtherRAILROAD MEDICARE
GA525985740OtherBLUE CROSS BLUE SHIELD
E68654Medicare UPIN