Provider Demographics
NPI:1629053707
Name:MOORE, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
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 1:1008 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-1463
Mailing Address - Country:US
Mailing Address - Phone:417-667-3919
Mailing Address - Fax:
Practice Address - Street 1:1008 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-1463
Practice Address - Country:US
Practice Address - Phone:417-667-3919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR73542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200214005Medicaid
MO0003560Medicare ID - Type Unspecified
MOC52092Medicare UPIN