Provider Demographics
NPI:1437113651
Name:MOORE, LESLIE JARROTT (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JARROTT
Last Name:MOORE
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1333 TAYLOR ST STE 5F
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2951
Practice Address - Country:US
Practice Address - Phone:803-748-9966
Practice Address - Fax:803-748-7174
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32261208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322617Medicaid
SCP00944488OtherMEDICARE RAILROAD
SC322617Medicaid
H96154Medicare UPIN