Provider Demographics
NPI:1306824545
Name:MOORE, MARILYNN W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYNN
Middle Name:W
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 E GREEN ST
Mailing Address - Street 2:#204
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106
Mailing Address - Country:US
Mailing Address - Phone:626-792-3843
Mailing Address - Fax:626-792-8320
Practice Address - Street 1:1060 E GREEN ST
Practice Address - Street 2:#204
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106
Practice Address - Country:US
Practice Address - Phone:626-792-3843
Practice Address - Fax:626-792-8320
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41466207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG414661Medicaid
CAG41466AMedicare PIN
G41466Medicare PIN
CAG41466Medicare ID - Type Unspecified
CAG414661Medicaid