Provider Demographics
NPI:1689655151
Name:MOORE, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
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 9132
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9132
Mailing Address - Country:US
Mailing Address - Phone:800-927-0002
Mailing Address - Fax:
Practice Address - Street 1:131 ORNAC
Practice Address - Street 2:JOHN CUMMINGS BLDG
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4181
Practice Address - Country:US
Practice Address - Phone:781-259-0803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29410174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB23053OtherBCBS
MA029410OtherTUFTS
MA11461OtherHARVARD PILGRIM
MA000000024368OtherBMC HEALTHNET
MA3196640Medicaid
MA05-04349OtherUNITED HEALTHCARE
MA000000024368OtherBMC HEALTHNET
MAB23053OtherBCBS
MA029410OtherTUFTS