Provider Demographics
NPI:1225193329
Name:LARRY R MOORMAN M D, PC
Entity Type:Organization
Organization Name:LARRY R MOORMAN M D, PC
Other - Org Name:TIFTON OPHTHALMOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-386-2181
Mailing Address - Street 1:1803 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1617
Mailing Address - Country:US
Mailing Address - Phone:229-386-2181
Mailing Address - Fax:229-386-2193
Practice Address - Street 1:1803 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-386-2181
Practice Address - Fax:229-386-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014938207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0774710001OtherCIGNA
CC4435OtherRAILROAD MEDICARE
GRP2612OtherMEDICARE