Provider Demographics
NPI:1710167473
Name:MOORMAN, DREW
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:MOORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 FAIRVIEW PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2565
Mailing Address - Country:US
Mailing Address - Phone:478-304-1414
Mailing Address - Fax:478-353-1353
Practice Address - Street 1:104 FAIRVIEW PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-304-1414
Practice Address - Fax:478-353-1353
Is Sole Proprietor?:No
Enumeration Date:2007-11-10
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200800294208000000X
GA80961208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003210067Medicaid
NC2008-00294OtherSTATE LICENSE
SCN0029IMedicaid
NC1710167473Medicaid
NC5909874Medicaid