Provider Demographics
NPI:1326076274
Name:MOORE, WISTAR III (MD)
Entity Type:Individual
Prefix:
First Name:WISTAR
Middle Name:
Last Name:MOORE
Suffix:III
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:801 E 6TH ST STE 307
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3663
Practice Address - Country:US
Practice Address - Phone:850-785-9559
Practice Address - Fax:850-608-6423
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64685208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375218600Medicaid
FL23256QOtherMEDICARE CITRUS CV ASSOCIATES, PL
FL23256OtherBCBS FL
FL23256POtherMEDICARE STUART CV ASSOCIATES, PLLC
FL23256UOtherMEDICARE LEESBURG CV ASSOCIATES, LLC
FL23256POtherMEDICARE STUART CV ASSOCIATES, PLLC
FL23256OtherBCBS FL
FLP00139531Medicare PIN
FL23256VMedicare PIN
FL23256UMedicare PIN
FL23256XMedicare PIN
FL23256SMedicare PIN
FL23256QOtherMEDICARE CITRUS CV ASSOCIATES, PL