Provider Demographics
NPI:1710047832
Name:MOORE, DANIEL W (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3901 ROSWELL RD STE 225
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8816
Mailing Address - Country:US
Mailing Address - Phone:770-424-2025
Mailing Address - Fax:770-425-1789
Practice Address - Street 1:3901 ROSWELL RD STE 225
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8816
Practice Address - Country:US
Practice Address - Phone:770-424-2025
Practice Address - Fax:770-425-1789
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00608539BMedicaid