Provider Demographics
NPI:1578989059
Name:MOORE, DOROTHY GWEN (MD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:GWEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 N PAULINA AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3022
Mailing Address - Country:US
Mailing Address - Phone:310-372-1998
Mailing Address - Fax:
Practice Address - Street 1:626 N PAULINA AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3022
Practice Address - Country:US
Practice Address - Phone:310-372-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine