Provider Demographics
NPI:1578584298
Name:MOORE, JULIA F (MD)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:F
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:F
Other - Last Name:TYBOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-0565
Mailing Address - Country:US
Mailing Address - Phone:360-385-0321
Mailing Address - Fax:360-379-5534
Practice Address - Street 1:884 W PARK AVE
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2273
Practice Address - Country:US
Practice Address - Phone:360-385-0321
Practice Address - Fax:360-379-5534
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17254-0202084P0800X, 2084P0804X
WAMD000159452084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34260900Medicaid
A05208OtherCIGNA
42572OtherNETWORK HEALTH PLAN
42572OtherNETWORK HEALTH PLAN
A05208Medicare UPIN
WI0010-38240Medicare ID - Type Unspecified