Provider Demographics
NPI:1760008460
Name:MOORE, DOUGLAS G
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:G
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-4844
Mailing Address - Country:US
Mailing Address - Phone:302-607-5011
Mailing Address - Fax:
Practice Address - Street 1:1801 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3503
Practice Address - Country:US
Practice Address - Phone:410-354-2800
Practice Address - Fax:410-225-5452
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD789101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)