Provider Demographics
NPI:1720140536
Name:MOARD, DOUGLAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PAUL
Last Name:MOARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3298
Mailing Address - Fax:
Practice Address - Street 1:W5282 AMY AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-7233
Practice Address - Country:US
Practice Address - Phone:920-358-1900
Practice Address - Fax:920-358-1909
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26838-020207Q00000X
WI268382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB55167Medicare UPIN