Provider Demographics
NPI:1528191012
Name:MOORE, STEPHEN III (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MOORE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 BUSH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7574
Mailing Address - Country:US
Mailing Address - Phone:919-875-8150
Mailing Address - Fax:919-235-0876
Practice Address - Street 1:3500 BUSH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7574
Practice Address - Country:US
Practice Address - Phone:919-875-8150
Practice Address - Fax:919-235-0876
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8960529Medicaid
NC203438BMedicare ID - Type UnspecifiedMEDICARE
NC8960529Medicaid