Provider Demographics
NPI:1235160573
Name:MOORE, EDWIN A (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:6201 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6712
Practice Address - Country:US
Practice Address - Phone:800-424-3672
Practice Address - Fax:954-377-3042
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7951207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260082000Medicaid
C28819Medicare UPIN
FL49453ZMedicare ID - Type Unspecified