Provider Demographics
NPI:1609819416
Name:MOORE, ALFRED DENTON (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:DENTON
Last Name:MOORE
Suffix:
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:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29602-0287
Mailing Address - Country:US
Mailing Address - Phone:864-729-8330
Mailing Address - Fax:864-751-0479
Practice Address - Street 1:975 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4241
Practice Address - Country:US
Practice Address - Phone:864-729-8330
Practice Address - Fax:864-751-0479
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC010654207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC106548Medicaid
SCP00211213OtherRAILROAD-MEDICARE
SCP00211213OtherRAILROAD-MEDICARE