Provider Demographics
NPI:1245223114
Name:MOORE, JUDSON B (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:B
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 729
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-0729
Mailing Address - Country:US
Mailing Address - Phone:334-793-2663
Mailing Address - Fax:334-836-2247
Practice Address - Street 1:1500 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4754
Practice Address - Country:US
Practice Address - Phone:334-793-2663
Practice Address - Fax:334-836-2247
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26641207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA681240743CMedicaid
AL515-28492OtherBCBS OF AL 1500 RCC
AL009996985Medicaid
AL121888Medicaid
AL511-08313OtherBCBS OF AL - HEALTHWEST
GA681240743AMedicaid
GA681240743CMedicaid
AL051528492MOOMedicare ID - Type Unspecified