Provider Demographics
NPI:1801856927
Name:MOORE, CAROL J (DPM)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11308 DISTINCTIVE DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9459
Mailing Address - Country:US
Mailing Address - Phone:708-479-6460
Mailing Address - Fax:708-479-6462
Practice Address - Street 1:11308 DISTINCTIVE DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9459
Practice Address - Country:US
Practice Address - Phone:708-479-6460
Practice Address - Fax:708-479-6462
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004283213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004283OtherILLINOIS LICENSE NUMBER
IL212901Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ILT87138Medicare UPIN
IL016004283OtherILLINOIS LICENSE NUMBER