Provider Demographics
NPI:1598269920
Name:MORAN, TERRY ANTHONY JR (DO)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:ANTHONY
Last Name:MORAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-795-0659
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1407 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-3369
Practice Address - Country:US
Practice Address - Phone:601-795-0659
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27169207P00000X, 207Q00000X
LA320935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2463845Medicaid