Provider Demographics
NPI:1366431983
Name:MOISE, GUY RUDOLPH (DO)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:RUDOLPH
Last Name:MOISE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 NW 120TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-2529
Mailing Address - Country:US
Mailing Address - Phone:305-688-0811
Mailing Address - Fax:305-687-5831
Practice Address - Street 1:650 NW 120TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168-2529
Practice Address - Country:US
Practice Address - Phone:305-688-0811
Practice Address - Fax:305-687-5831
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 0004440208D00000X
FLOS4440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03674OtherWELLCARE
FL068084200Medicaid
FL03674OtherSTAYWELL HEALTH PLAN
FL210849OtherAMERIGROUP
FLE12050OtherVISTA HEALTH PLAN
FL004303OtherNHP
FL82599OtherBCBS
FL03674OtherWELLCARE
FL03674OtherSTAYWELL HEALTH PLAN