Provider Demographics
NPI:1003893439
Name:MOORE, TIMOTHY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:MOORE
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:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-715-5007
Mailing Address - Fax:972-715-5682
Practice Address - Street 1:8200 WALNUT HILL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4426
Practice Address - Country:US
Practice Address - Phone:214-345-6148
Practice Address - Fax:214-345-4322
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0652207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130384404Medicaid
TX130384405Medicaid
E07165Medicare UPIN
TX130384405Medicaid
TX89134KMedicare PIN
TX88954KMedicare PIN