Provider Demographics
NPI:1508003849
Name:MOORE, MELINDA BETH (DPM)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:BETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1528
Mailing Address - Country:US
Mailing Address - Phone:618-985-3338
Mailing Address - Fax:618-985-3339
Practice Address - Street 1:807 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1528
Practice Address - Country:US
Practice Address - Phone:618-985-3338
Practice Address - Fax:618-985-3338
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005343213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00798192Medicare PIN
IL560750005Medicare PIN
IL560750005Medicare PIN