Provider Demographics
NPI:1689633935
Name:MOORE, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:609 S CHRISTOPHER RD
Practice Address - Street 2:PMG BELEN
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002
Practice Address - Country:US
Practice Address - Phone:505-864-5454
Practice Address - Fax:505-864-5450
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0160207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK6868Medicaid
D46175Medicare UPIN
343625403Medicare PIN