Provider Demographics
NPI:1356332670
Name:MOORE, CHERYL (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
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 1:680 CENTRE STREET
Mailing Address - Street 2:PATHOLOGY DEPARTMENT
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7000
Mailing Address - Fax:508-941-6104
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11761207ZP0102X
ME016067207ZP0102X
MA216651207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110033126AMedicaid
ME305920099Medicaid
NH30203266Medicaid
11098339OtherCAQH#