Provider Demographics
NPI:1053304097
Name:MOELLER, MARK B (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:MOELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-633-1010
Mailing Address - Fax:252-224-3071
Practice Address - Street 1:137 MEDICAL LANE
Practice Address - Street 2:
Practice Address - City:POLLOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28573
Practice Address - Country:US
Practice Address - Phone:252-633-1010
Practice Address - Fax:252-224-3071
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC25731207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8959922Medicaid
NC202672EOtherMEDICARE PTAN
NC59922OtherBLUE CROSS
C81408Medicare UPIN
NC8959922Medicaid