Basic Information
| Provider Information | |||||||||
| NPI: | 1750360889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOATS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E PLAZA DR | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934546953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059223632 | ||||||||
| FaxNumber: | 8059223522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | G30085 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00G300850 | 05 | CA | MEDICAID | 00G300850 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |