Provider Demographics
NPI:1336127513
Name:MOORE, MARTHA JEANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEANNE
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:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-0346
Mailing Address - Country:US
Mailing Address - Phone:931-403-1197
Mailing Address - Fax:931-403-2615
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1718
Practice Address - Country:US
Practice Address - Phone:931-823-5681
Practice Address - Fax:931-823-8203
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058674L207Q00000X
TN45921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0737905OtherAETNA
PA251830873OtherCOMMERCIAL
PA93789OtherHEALTH AMERICA ASSURANCE
TNQ024962Medicaid
PAMO838156OtherHIGHMARK
PA0709123OtherUNITED HEALTHCARE
PA987266OtherHIGHMARK
PAMO838156Medicare PIN
TN103I086348Medicare PIN
PAMO838156OtherHIGHMARK