Provider Demographics
NPI:1700839487
Name:MOORE, W. TABB (MD)
Entity Type:Individual
Prefix:
First Name:W.
Middle Name:TABB
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 418283
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8283
Mailing Address - Country:US
Mailing Address - Phone:703-558-1544
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDB08033207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00894810OtherRAILROAD MEDICARE
MD330103600Medicaid
DC169657YT2Medicare PIN
MD111XMedicare ID - Type UnspecifiedINDIVIDUAL
DCP00894810OtherRAILROAD MEDICARE
MDD18010Medicare UPIN