Provider Demographics
NPI:1164432522
Name:MOORE, MARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1750 THOMPSON RD
Mailing Address - Street 2:BAY CLINIC LLP
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-269-0333
Mailing Address - Fax:541-267-7389
Practice Address - Street 1:1750 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-269-0333
Practice Address - Fax:541-269-7389
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics