Provider Demographics
NPI:1316035413
Name:MOORE, SUSAN S (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5396 HIDDEN GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-4201
Mailing Address - Country:US
Mailing Address - Phone:904-553-4644
Mailing Address - Fax:
Practice Address - Street 1:6271 SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2523
Practice Address - Country:US
Practice Address - Phone:904-633-0460
Practice Address - Fax:904-633-0461
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME92420208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275686200Medicaid