Provider Demographics
NPI:1659931046
Name:MOORE, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SHURS LANE SUITE 301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:NJ
Mailing Address - Zip Code:19127-2629
Mailing Address - Country:US
Mailing Address - Phone:215-482-1234
Mailing Address - Fax:
Practice Address - Street 1:10 SHURS LN STE 301
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-2123
Practice Address - Country:US
Practice Address - Phone:215-967-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT219038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty