Provider Demographics
NPI:1538110911
Name:MOORE, MICHAEL BENJAMIN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 FITZSIMMONS DR
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431-3689
Mailing Address - Country:US
Mailing Address - Phone:253-968-1340
Mailing Address - Fax:
Practice Address - Street 1:9040 FITZSIMMONS DR
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-3689
Practice Address - Country:US
Practice Address - Phone:253-968-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1198208D00000X, 207Q00000X
WAOP61069996207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine