Provider Demographics
NPI:1710940176
Name:MOORE, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:450 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5599
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:662-377-2755
Practice Address - Street 1:830 S GLOSTER ST
Practice Address - Street 2:4TH FLOOR EAST TOWER
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4934
Practice Address - Country:US
Practice Address - Phone:662-377-7150
Practice Address - Fax:662-377-7155
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07340207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115011Medicaid
MS00115011Medicaid