Provider Demographics
NPI:1518978881
Name:MOORMAN, LARRY RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:RUSSELL
Last Name:MOORMAN
Suffix:
Gender:M
Credentials:MD
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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
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-04-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA014938207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000018334A4Medicaid
GA$$$$$$$$$AMedicare PIN
GAD30280Medicare UPIN