Provider Demographics
NPI:1518131754
Name:MOORE, BENJAMIN C (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:C
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5640
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:421 S 28TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7206
Practice Address - Country:US
Practice Address - Phone:601-268-5640
Practice Address - Fax:601-261-3507
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21901207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9496951OtherAETNA
MS04456312Medicaid
MS3493860OtherUNITED HEALTHCARE
MS4738806OtherCIGNA
MS6060931OtherHEALTHSPRING
MS6060931OtherHEALTHSPRING