Provider Demographics
NPI:1255406898
Name:MOY, JUSTIN RANDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RANDOLPH
Last Name:MOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 41516
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1516
Mailing Address - Country:US
Mailing Address - Phone:904-202-5111
Mailing Address - Fax:904-391-5836
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD STE 301
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5472
Practice Address - Country:US
Practice Address - Phone:904-202-6410
Practice Address - Fax:904-390-7382
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND13287207Y00000X
IN01061468A208D00000X
FLME128553207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice