Provider Demographics
NPI:1417121492
Name:MOORE, DOUGLAS WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-3604
Mailing Address - Country:US
Mailing Address - Phone:620-221-3033
Mailing Address - Fax:
Practice Address - Street 1:1230 E 6TH AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-3143
Practice Address - Country:US
Practice Address - Phone:620-221-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-21
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-36126207V00000X
OH34.009706207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology