Provider Demographics
NPI:1326093410
Name:MOORE, SHAWN P (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:P
Last Name:MOORE
Suffix:
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 1:10740 PALM RIVER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-4577
Mailing Address - Country:US
Mailing Address - Phone:813-651-3300
Mailing Address - Fax:813-651-4455
Practice Address - Street 1:2000 S MAYS ST STE 201
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7580
Practice Address - Country:US
Practice Address - Phone:512-244-4272
Practice Address - Fax:512-244-2895
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24838174400000X
AL37505207T00000X
KS04-32207207T00000X
FLME141772207T00000X
TXR6846207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200079770AMedicaid
OK24838OtherOKLAHOMA STATE ID#
AR186639001Medicaid
KS200418720AMedicaid
KS200418720AMedicaid
KS067359Medicare PIN