Provider Demographics
NPI:1275030850
Name:MOORE, LAURENCE NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:NICHOLAS
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 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3209 DRYDEN DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3015
Practice Address - Country:US
Practice Address - Phone:608-241-9020
Practice Address - Fax:608-240-4237
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD200222207Q00000X
CAA177529207Q00000X
WI81814-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine