Provider Demographics
NPI:1376530758
Name:MOORE, MARIBETH DUDLEY (DO)
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:DUDLEY
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 RIVERWOOD CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2890
Mailing Address - Country:US
Mailing Address - Phone:936-760-4454
Mailing Address - Fax:936-760-4415
Practice Address - Street 1:800 RIVERWOOD CT
Practice Address - Street 2:SUITE 105
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2890
Practice Address - Country:US
Practice Address - Phone:936-760-4454
Practice Address - Fax:936-760-4415
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046741706Medicaid
TX8349B9Medicare ID - Type Unspecified
TXG28466Medicare UPIN