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
State | License ID | Taxonomies |
---|---|---|
OH | 57.249165 | 390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 57.249165 | Other | STATE OF OHIO TRAINING CERTIFICATE |