Provider Demographics
NPI:1275558371
Name:MOORE, MARCELLUS H (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCELLUS
Middle Name:H
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 1:81225 KINGSTON HEATH
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-8741
Mailing Address - Country:US
Mailing Address - Phone:213-427-1148
Mailing Address - Fax:
Practice Address - Street 1:81225 KINGSTON HEATH
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8741
Practice Address - Country:US
Practice Address - Phone:213-427-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51387207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC51387Medicare ID - Type UnspecifiedPROVIDER NUMBER