Provider Demographics
NPI:1356320915
Name:MOORE, HAROLD GUY (MD)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:GUY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-5200
Mailing Address - Fax:208-302-5225
Practice Address - Street 1:1880 W JUDITH LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5221
Practice Address - Country:US
Practice Address - Phone:208-302-5200
Practice Address - Fax:208-302-5225
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-12305207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF28683Medicare UPIN
WAF28683Medicare UPIN
WA8249716Medicaid