Provider Demographics
NPI:1942859483
Name:MOORE, DAVID CARSON
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CARSON
Last Name:MOORE
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 1:316 VILLAGE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-5387
Mailing Address - Country:US
Mailing Address - Phone:864-327-9003
Mailing Address - Fax:
Practice Address - Street 1:316 VILLAGE CREEK DR
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316-5387
Practice Address - Country:US
Practice Address - Phone:864-327-9003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-07
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA3438207QA0000X, 208000000X, 2080A0000X
363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4061PAMedicaid
SCSCG971J6067OtherMEDICARE PIN
SCSCG9716084OtherMEDICARE PIN
SCSCG971J577OtherMEDICARE PIN