Provider Demographics
NPI:1811036692
Name:MOORE, MAC E (MD)
Entity Type:Individual
Prefix:
First Name:MAC
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3130 SW 89TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7907
Mailing Address - Country:US
Mailing Address - Phone:405-692-3737
Mailing Address - Fax:405-692-3707
Practice Address - Street 1:3130 SW 89TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7907
Practice Address - Country:US
Practice Address - Phone:405-692-3737
Practice Address - Fax:405-692-3707
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202816207X00000X
OKOK23409207X00000X
OK23409207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4M1566770Medicare PIN
LA4M156B103Medicare PIN