Provider Demographics
NPI:1710091020
Name:MOORE, THEODORE BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:BRUCE
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 1:10833 LE CONTE AVE
Mailing Address - Street 2:12-441 MDCC
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-6708
Mailing Address - Fax:310-206-8089
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:12-441 MDCC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-6708
Practice Address - Fax:310-206-8089
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG693082080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053510Medicaid
CA00G693080Medicaid
CAF81906Medicare UPIN
CAWG69308AMedicare ID - Type Unspecified
CA00G693080Medicaid