Provider Demographics
NPI:1932298437
Name:MOORE-BOATWRIGHT, DONNA RUTH
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:RUTH
Last Name:MOORE-BOATWRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2762 DORA AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4970
Mailing Address - Country:US
Mailing Address - Phone:352-742-7837
Mailing Address - Fax:352-742-7837
Practice Address - Street 1:2762 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4970
Practice Address - Country:US
Practice Address - Phone:352-742-7837
Practice Address - Fax:352-742-7837
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 101072083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889168100Medicaid