Provider Demographics
NPI:1467411645
Name:MOORE, CRAIG BEATY (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:BEATY
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 1:125 NORTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651
Mailing Address - Country:US
Mailing Address - Phone:580-726-5653
Mailing Address - Fax:580-726-3661
Practice Address - Street 1:125 NORTH BROADWAY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651
Practice Address - Country:US
Practice Address - Phone:580-726-5653
Practice Address - Fax:580-726-3661
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D35060Medicare UPIN