Provider Demographics
NPI:1417945700
Name:MOORE, PAUL DEREK (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DEREK
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N CAMERON ST
Mailing Address - Street 2:SUITE 401E
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-2424
Mailing Address - Country:US
Mailing Address - Phone:717-232-8535
Mailing Address - Fax:717-232-8515
Practice Address - Street 1:815 CUMBERLAND ST
Practice Address - Street 2:SUITE 205
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-5266
Practice Address - Country:US
Practice Address - Phone:717-277-7400
Practice Address - Fax:717-277-7402
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO40759207Q00000X
PAMD444618208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09932861Medicaid
CO09932861Medicaid
H93750Medicare UPIN