Provider Demographics
NPI:1780777995
Name:MORIARTY, GERALD L (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:MORIARTY
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 1:516 DELAWARE ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0356
Mailing Address - Country:US
Mailing Address - Phone:612-626-6688
Mailing Address - Fax:612-625-7950
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-626-6688
Practice Address - Fax:612-625-7950
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN352922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410897300Medicaid
MN410897300Medicaid
MN130000442Medicare ID - Type Unspecified