Provider Demographics
NPI:1568557577
Name:MOORE, THOMAS WYLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WYLIE
Last Name:MOORE
Suffix:
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 1:13811 MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4903
Mailing Address - Country:US
Mailing Address - Phone:713-772-1200
Mailing Address - Fax:281-491-0426
Practice Address - Street 1:16651 SOUTHWEST FWY
Practice Address - Street 2:SUITE 360
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2345
Practice Address - Country:US
Practice Address - Phone:713-772-1200
Practice Address - Fax:281-491-0426
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4371208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20033056OtherMEDICARE RR
TX5834481OtherAETNA
TX10018768OtherAMERIGROUP
TX3974024OtherCIGNA
TX0479214-01Medicaid
TX5834481OtherAETNA
TX10018768OtherAMERIGROUP