Provider Demographics
NPI:1588654552
Name:MOORE, ABIGAIL DOROTHY (DO)
Entity Type:Individual
Prefix:DR
First Name:ABIGAIL
Middle Name:DOROTHY
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ABIGAIL
Other - Middle Name:DOROTHY
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2323 E GREENLAW LN STE 10
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1849
Mailing Address - Country:US
Mailing Address - Phone:928-863-4692
Mailing Address - Fax:818-338-2566
Practice Address - Street 1:2323 E GREENLAW LN STE 10
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1849
Practice Address - Country:US
Practice Address - Phone:928-863-4692
Practice Address - Fax:818-338-2566
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360947842084P0800X
IN02003244A2084P0800X
AZ38402084P0800X
AZ0105722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ741018Medicaid
AZ74997Medicare ID - Type Unspecified
ILF20870Medicare UPIN
AZ741018Medicaid