Provider Demographics
NPI:1013178110
Name:MOORE, JUSTIN M (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:MOORE
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:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-5830
Mailing Address - Fax:864-224-4999
Practice Address - Street 1:4120 HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29626-5321
Practice Address - Country:US
Practice Address - Phone:864-512-5830
Practice Address - Fax:864-224-4999
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL31007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003111684AMedicaid
SC310078Medicaid
SCP01170009OtherRR MEDICARE
SCAA58947043Medicare PIN