Provider Demographics
NPI:1083633887
Name:MOORE, MARCUS A (DO)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 WILD DAISY CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4984
Mailing Address - Country:US
Mailing Address - Phone:248-921-9524
Mailing Address - Fax:
Practice Address - Street 1:6770 DIXIE HWY STE 200
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2089
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-8938
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101015942207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101015942OtherPHYSICIAN LICENSE
MI5315024072OtherCONTROLLED SUBSTANCE