Provider Demographics
NPI:1669476008
Name:MOORE, EARLE W (MD)
Entity Type:Individual
Prefix:
First Name:EARLE
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:523 CAPE CORAL PKWY E
Mailing Address - Street 2:PRIMARY CARE ASSOC.
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8545
Mailing Address - Country:US
Mailing Address - Phone:239-549-2772
Mailing Address - Fax:239-549-2332
Practice Address - Street 1:523 CAPE CORAL PKWY E
Practice Address - Street 2:PRIMARY CARE ASSOC.
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8545
Practice Address - Country:US
Practice Address - Phone:239-549-2772
Practice Address - Fax:239-549-2332
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007610114Medicaid
B10395Medicare UPIN
VA007610114Medicaid
H0992ZMedicare PIN
1669476008Medicare PIN