Provider Demographics
NPI:1457465171
Name:MOORER, GLYNDA MELONSON (MD)
Entity Type:Individual
Prefix:DR
First Name:GLYNDA
Middle Name:MELONSON
Last Name:MOORER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:OLIN HEALTH CENTER
Mailing Address - Street 2:EAST CIRCLE DRIVE
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-1037
Mailing Address - Country:US
Mailing Address - Phone:517-884-6546
Mailing Address - Fax:
Practice Address - Street 1:EAST CIRCLE DRIVE
Practice Address - Street 2:OLIN HEALTH CENTER
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824
Practice Address - Country:US
Practice Address - Phone:517-355-4510
Practice Address - Fax:517-432-9528
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1375049Medicaid
MI0C36019004Medicare PIN
MAF19364Medicare UPIN