Provider Demographics
NPI:1578002317
Name:MOORE, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:989-839-3000
Mailing Address - Fax:
Practice Address - Street 1:3051 KIESEL RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2449
Practice Address - Country:US
Practice Address - Phone:989-778-2900
Practice Address - Fax:989-778-2901
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101025385207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty