Provider Demographics
NPI:1659443539
Name:MOORE, JUDITH S (DO)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-6806
Mailing Address - Country:US
Mailing Address - Phone:435-657-1777
Mailing Address - Fax:435-657-0098
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049-6806
Practice Address - Country:US
Practice Address - Phone:435-657-1777
Practice Address - Fax:435-657-0098
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2011-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT180388-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E99335Medicare UPIN
005538501Medicare ID - Type Unspecified