Provider Demographics
NPI:1609400118
Name:MOORE, DOREATHA (CMA)
Entity Type:Individual
Prefix:MRS
First Name:DOREATHA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 N BLACK HORSE PIKE STE 2
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-9132
Mailing Address - Country:US
Mailing Address - Phone:866-582-7774
Mailing Address - Fax:866-624-7832
Practice Address - Street 1:2030 N BLACK HORSE PIKE STE 2
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-9132
Practice Address - Country:US
Practice Address - Phone:866-582-7774
Practice Address - Fax:866-624-7832
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCMA4623331L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes331L00000XSuppliersBlood Bank