Provider Demographics
NPI:1891806667
Name:MOORE, DARALL J (DPM)
Entity Type:Individual
Prefix:DR
First Name:DARALL
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1140
Mailing Address - Country:US
Mailing Address - Phone:727-321-8806
Mailing Address - Fax:727-321-6838
Practice Address - Street 1:4200 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1140
Practice Address - Country:US
Practice Address - Phone:727-321-8806
Practice Address - Fax:727-321-6838
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1999213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041420400Medicaid
FLT87848Medicare UPIN
FL65076Medicare ID - Type Unspecified
FL5192590001Medicare NSC