Provider Demographics
NPI:1497767792
Name:MOORE, J DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1491 ALTAMONT RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-6211
Mailing Address - Country:US
Mailing Address - Phone:864-546-8284
Mailing Address - Fax:864-315-3736
Practice Address - Street 1:23 BUENA VISTA WAY, STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-315-3736
Practice Address - Fax:864-315-3736
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0401662084P0800X
SC351692084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC351693Medicaid
SC351693Medicaid