Provider Demographics
NPI:1023094901
Name:MOORE, MONTE H (MD)
Entity type:Individual
Prefix:
First Name:MONTE
Middle Name:H
Last Name:MOORE
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 1:600 ROBBINS RD
Mailing Address - Street 2:SUITE #300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4565
Mailing Address - Country:US
Mailing Address - Phone:208-489-4016
Mailing Address - Fax:
Practice Address - Street 1:600 ROBBINS RD
Practice Address - Street 2:SUITE #300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-489-4016
Practice Address - Fax:208-489-4015
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6331208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF61825Medicare UPIN