Provider Demographics
NPI:1295794089
Name:PREMJI, MOEZ R (MD)
Entity type:Individual
Prefix:
First Name:MOEZ
Middle Name:R
Last Name:PREMJI
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 1:308 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37771-3043
Mailing Address - Country:US
Mailing Address - Phone:865-988-5774
Mailing Address - Fax:865-988-5776
Practice Address - Street 1:308 E BDWY
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-3043
Practice Address - Country:US
Practice Address - Phone:865-988-5774
Practice Address - Fax:865-988-5776
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39023207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG12422Medicare UPIN
TN3339675Medicare ID - Type Unspecified