Provider Demographics
NPI:1326025156
Name:MOORE, CAROL E (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:E
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 1:2828 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4138
Mailing Address - Country:US
Mailing Address - Phone:336-794-1444
Mailing Address - Fax:336-794-1477
Practice Address - Street 1:2828 MAPLEWOOD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4138
Practice Address - Country:US
Practice Address - Phone:336-794-1444
Practice Address - Fax:336-794-1477
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19065174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1766Medicaid
SCE94019Medicare UPIN
SCE940195485Medicare PIN