Provider Demographics
NPI:1295835924
Name:CRISP, LADDIE MOORE JR (MD)
Entity Type:Individual
Prefix:
First Name:LADDIE
Middle Name:MOORE
Last Name:CRISP
Suffix:JR
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 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1603
Practice Address - Country:US
Practice Address - Phone:252-527-4146
Practice Address - Fax:252-527-5697
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5868476OtherAETNA INSURANCE
NC8925754Medicaid
NC25754OtherBCBS/NC
NC01-28746OtherUNITED HEALTHCARE
NC41528OtherMEDCOST
NC5868476OtherAETNA INSURANCE