Provider Demographics
NPI:1629020011
Name:MOORE, CHARLES HENRY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
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 1:2206 E VILLA MARIA RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2547
Mailing Address - Country:US
Mailing Address - Phone:979-776-4600
Mailing Address - Fax:
Practice Address - Street 1:2206 E VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2547
Practice Address - Country:US
Practice Address - Phone:979-776-4600
Practice Address - Fax:979-776-8749
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4612207RG0100X
TXM4372207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology