Provider Demographics
NPI:1003824004
Name:MOORE, WAYNE E (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:901 LINCOLNWAY
Practice Address - Street 2:STE 304
Practice Address - City:LAPORTE
Practice Address - State:IN
Practice Address - Zip Code:46350
Practice Address - Country:US
Practice Address - Phone:219-362-8523
Practice Address - Fax:219-324-9396
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01038003A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
01038003OtherLICENSE NUMBER
IN100367770AMedicaid
IN01038003BOtherCSR
INBM2144474OtherDEA
INBM2144474OtherDEA
INM400022978Medicare PIN
E33590Medicare UPIN