Provider Demographics
NPI:1376507608
Name:MOORE, MARLA J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:J
Last Name:MOORE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5731
Mailing Address - Fax:719-447-8987
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5731
Practice Address - Fax:719-447-8987
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-10-27
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Provider Licenses
StateLicense IDTaxonomies
CO364442080P0203X
COCO364442080P0203X
HIMD115452080P0203X
MN1057962080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32804377Medicaid
H45819Medicare UPIN