Provider Demographics
NPI:1639162795
Name:MOY, MANNY (DPM)
Entity Type:Individual
Prefix:DR
First Name:MANNY
Middle Name:
Last Name:MOY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 SE LAKE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:506-659-6686
Mailing Address - Fax:503-905-6202
Practice Address - Street 1:6542 SE LAKE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2138
Practice Address - Country:US
Practice Address - Phone:506-659-6686
Practice Address - Fax:503-905-6202
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000333213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5252800001Medicare NSC
ORU85812Medicare UPIN