Provider Demographics
NPI:1518595701
Name:MOORE, ANNA ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
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:WSU FAMILY MEDICINE RESIDENCY
Mailing Address - Street 2:2261 PHILADELPHIA DR. SUITE 300
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406
Mailing Address - Country:US
Mailing Address - Phone:937-734-4141
Mailing Address - Fax:937-277-7249
Practice Address - Street 1:FIVE RIVERS FAMILY HEALTH CENTER
Practice Address - Street 2:2261 PHILADELPHIA DR. SUITE 301
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406
Practice Address - Country:US
Practice Address - Phone:937-734-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.249165390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH57.249165OtherSTATE OF OHIO TRAINING CERTIFICATE