Provider Demographics
NPI:1184725558
Name:MOELLER, DEREK (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MOELLER
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 1:1114 COMMONWEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9301
Mailing Address - Country:US
Mailing Address - Phone:662-456-3437
Mailing Address - Fax:662-452-2070
Practice Address - Street 1:208 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-9326
Practice Address - Country:US
Practice Address - Phone:662-456-3437
Practice Address - Fax:662-452-2070
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17537207R00000X
MSMS17537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125350Medicaid
MS09013750Medicaid
MS09013750Medicaid
MS302I118926Medicare PIN