Provider Demographics
NPI:1245290212
Name:MOORE, CHARLES C JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:C
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-0168
Mailing Address - Country:US
Mailing Address - Phone:804-353-4000
Mailing Address - Fax:804-213-9783
Practice Address - Street 1:7603 FOREST AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4942
Practice Address - Country:US
Practice Address - Phone:804-741-0440
Practice Address - Fax:804-288-2277
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024051207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06527OtherMEDICARE GROUP NUMBER
VA006203035Medicaid
160001766Medicare ID - Type Unspecified
VA006203035Medicaid