Provider Demographics
NPI:1184041675
Name:MOORE, WILLIE JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:JR
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-2735
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101262656208M00000X
390200000X
NC2020-04125208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program