Provider Demographics
NPI:1235133562
Name:MOORE, DONALD HALSTEAD (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:HALSTEAD
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 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:1097 FLEDDERJOHN RD STE 1
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-4208
Practice Address - Country:US
Practice Address - Phone:304-345-3627
Practice Address - Fax:304-346-4440
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13276207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049OtherMEDICAID-GROUP
WV0057103000Medicaid
WVB441OtherMEDICARE-GROUP
WVA72648Medicare UPIN
WV3810024049OtherMEDICAID-GROUP