Provider Demographics
NPI:1518211408
Name:MOORE, CRAIG M (CSFA)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2626
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2626
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:7451 CHAPEL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7090
Practice Address - Country:US
Practice Address - Phone:817-294-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX138996246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX95869OtherCST