Provider Demographics
NPI:1821149451
Name:MOORE, MARNELL PAUL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARNELL
Middle Name:PAUL
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:310 CENTRAL AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2835
Mailing Address - Country:US
Mailing Address - Phone:973-337-2893
Mailing Address - Fax:201-228-1689
Practice Address - Street 1:310 CENTRAL AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2835
Practice Address - Country:US
Practice Address - Phone:973-337-2893
Practice Address - Fax:201-228-1689
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00289000213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
112896WU2Medicare PIN