Provider Demographics
NPI:1598736696
Name:MOORE, THOMAS WELLER JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WELLER
Last Name:MOORE
Suffix:JR
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:HQ MEDDAC B
Mailing Address - Street 2:UNIT 28037 BLDG 700
Mailing Address - City:APO
Mailing Address - State:NY
Mailing Address - Zip Code:09112
Mailing Address - Country:US
Mailing Address - Phone:314-590-2368
Mailing Address - Fax:
Practice Address - Street 1:HQ MEDDACB
Practice Address - Street 2:UNIT 28037 BLDG 700
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:US
Practice Address - Phone:314-590-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC331554Medicaid
SCAA61457951Medicare PIN