Provider Demographics
NPI:1508859166
Name:MOORE, LEE S (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:S
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:320 N OAK AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2440
Practice Address - Country:US
Practice Address - Phone:931-528-5547
Practice Address - Fax:931-526-2699
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15695208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3378641Medicaid
TN340011880OtherRAILROAD MEDICARE
TN6524763OtherCIGNA HEALTHCARE
TN94833OtherBLUE CROSS BLUE SHEILD
TN1940006OtherUNITED HEALTH CARE
TN1940006OtherUNITED HEALTH CARE
TN3378641Medicaid