Provider Demographics
NPI:1821286535
Name:MOORHEAD, CHRISTINE E (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:E
Last Name:MOORHEAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:E
Other - Last Name:MOORHEADDOURE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:151 SOUTHHALL LN STE 200
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:2893 ENTERPRISE RD STE 100
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2784
Practice Address - Country:US
Practice Address - Phone:386-789-8600
Practice Address - Fax:386-789-0219
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95181207N00000X
FLME105152207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11995801OtherCAQH
FL001380400Medicaid
FL001380400Medicaid