Provider Demographics
NPI:1962444539
Name:MOOREHEAD, MORRILL T (MD)
Entity Type:Individual
Prefix:
First Name:MORRILL
Middle Name:T
Last Name:MOOREHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-425-5620
Mailing Address - Fax:360-425-7219
Practice Address - Street 1:1217 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3018
Practice Address - Country:US
Practice Address - Phone:360-425-5620
Practice Address - Fax:360-425-7219
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA44028207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8410151Medicaid
F13350Medicare UPIN
WA88501736Medicare ID - Type Unspecified