Provider Demographics
NPI:1013108653
Name:MOORE, GREGORY TODD (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:TODD
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2901 ACME BRICK PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4124
Mailing Address - Country:US
Mailing Address - Phone:817-529-1900
Mailing Address - Fax:817-529-1910
Practice Address - Street 1:305 REGENCY PKWY STE 405
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5169
Practice Address - Country:US
Practice Address - Phone:817-968-5806
Practice Address - Fax:915-703-7745
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP30020050207X00000X
TXN0287207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209173801Medicaid