Provider Demographics
NPI:1043639289
Name:JOSEPH S MOAK JR MD PA
Entity Type:Organization
Organization Name:JOSEPH S MOAK JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:RESTIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-833-5051
Mailing Address - Street 1:1040 BIGLANE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601
Mailing Address - Country:US
Mailing Address - Phone:601-833-5051
Mailing Address - Fax:601-835-0240
Practice Address - Street 1:1040 BIGLANE DRIVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601
Practice Address - Country:US
Practice Address - Phone:601-833-5051
Practice Address - Fax:601-835-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty