Provider Demographics
NPI:1134387293
Name:MOORE, DEREK W (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 BATH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4330
Mailing Address - Country:US
Mailing Address - Phone:805-682-7801
Mailing Address - Fax:805-687-5342
Practice Address - Street 1:2324 BATH ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4330
Practice Address - Country:US
Practice Address - Phone:805-682-7801
Practice Address - Fax:805-687-5342
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA238120207T00000X, 207XS0117X
NY237490207XS0117X
CAA87788207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2164035Medicaid
MAM20518Medicare PIN
MA000854901Medicare PIN