Provider Demographics
NPI:1083677934
Name:MOORE, EUGENE F (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:F
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:F
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:28 S WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-864-7080
Mailing Address - Fax:802-863-0411
Practice Address - Street 1:28 S WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-864-7080
Practice Address - Fax:802-863-0411
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042010189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2573Medicaid
VT00058102OtherBS
VT00058101OtherBS
VT00058102OtherBS
VTVN2573Medicare ID - Type Unspecified