Provider Demographics
NPI:1174635601
Name:MOOSE, DURMAN WILLIAM JR (MD)
Entity Type:Individual
Prefix:
First Name:DURMAN
Middle Name:WILLIAM
Last Name:MOOSE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 78030
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28271-7023
Mailing Address - Country:US
Mailing Address - Phone:704-458-9431
Mailing Address - Fax:704-844-0648
Practice Address - Street 1:1601 ABBEY PL
Practice Address - Street 2:STE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3835
Practice Address - Country:US
Practice Address - Phone:704-512-5360
Practice Address - Fax:704-512-5080
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32543208600000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN32543Medicaid
NC8960533Medicaid
SCN32543Medicaid
NCC89350Medicare UPIN