Provider Demographics
NPI:1962679241
Name:MOORE, PAUL H III (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:H
Last Name:MOORE
Suffix:III
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 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5306
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5306
Practice Address - Fax:601-984-6904
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22004207VF0040X
NY254426207VF0040X
AL31773207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05182213Medicaid
MS256992YS8TMedicare PIN