Provider Demographics
NPI:1881859478
Name:MOORE, SAMUEL A (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SAINT VINCENT CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5415
Mailing Address - Country:US
Mailing Address - Phone:501-663-6455
Mailing Address - Fax:501-663-4877
Practice Address - Street 1:5 SAINT VINCENT CIR STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5415
Practice Address - Country:US
Practice Address - Phone:501-663-6455
Practice Address - Fax:501-663-4877
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4668207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193245003Medicaid
5AQ34C201Medicare PIN