Provider Demographics
NPI:1770739872
Name:MOORE, DERRICK MONTEREY SR
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:MONTEREY
Last Name:MOORE
Suffix:SR
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 1:8325 POPLAR SPRINGS DR LOT 55
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-9243
Mailing Address - Country:US
Mailing Address - Phone:601-681-4582
Mailing Address - Fax:601-681-9642
Practice Address - Street 1:8325 POPLAR SPRINGS DR LOT 55
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-9243
Practice Address - Country:US
Practice Address - Phone:601-681-4582
Practice Address - Fax:601-681-9642
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS9205865172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02926254Medicaid