Provider Demographics
NPI:1083047401
Name:MOOTS, PAUL STUART (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:STUART
Last Name:MOOTS
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 1:929 W. LOIRE CT
Mailing Address - Street 2:APT 1211
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:217-825-4072
Mailing Address - Fax:
Practice Address - Street 1:929 W LOIRE CT
Practice Address - Street 2:APT 1211
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1850
Practice Address - Country:US
Practice Address - Phone:217-825-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125064267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine