Provider Demographics
NPI:1619926177
Name:MOORE, LAURA NOEL (MD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:NOEL
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:NOEL
Other - Last Name:BEVERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7171 HIGHWAY 19 S
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:GA
Mailing Address - Zip Code:30295-3598
Mailing Address - Country:US
Mailing Address - Phone:770-567-7293
Mailing Address - Fax:770-567-0614
Practice Address - Street 1:100 LINE CREEK DR
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1028
Practice Address - Country:US
Practice Address - Phone:770-847-8786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043094207P00000X, 207Q00000X
WAMD60541847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10636815OtherCAQH
GA000788477NMedicaid
GA043094OtherLICENSE
1619926177OtherNPI
GA043094OtherLICENSE
WAG8945600Medicare PIN
G71807Medicare UPIN