Provider Demographics
NPI:1073562476
Name:MOORE, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:5151 E. HWY 90
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635
Mailing Address - Country:US
Mailing Address - Phone:520-519-7720
Mailing Address - Fax:520-519-5181
Practice Address - Street 1:5151 E. HWY 90
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635
Practice Address - Country:US
Practice Address - Phone:520-803-6644
Practice Address - Fax:520-544-2943
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101122085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ237851Medicaid
AZ237851Medicaid
AZD44285Medicare UPIN
AZ86-0938204OtherTIN
Z25295Medicare PIN
AZZ25295Medicare PIN