Provider Demographics
NPI:1245293828
Name:MOORE, OLYN FRED III (MD)
Entity type:Individual
Prefix:DR
First Name:OLYN
Middle Name:FRED
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 1:503 TICKLE STREET
Mailing Address - Street 2:SUITE #1
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-285-5244
Mailing Address - Fax:731-285-8970
Practice Address - Street 1:503 TICKLE STREET
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-285-5244
Practice Address - Fax:731-285-8970
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD012164208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN117022OtherTENNCARE UNISOM
TN3008574Medicaid
TN2003420OtherBLUE CROSS BLUE SHIELD
TN117022OtherTENNCARE UNISOM
TN3008574Medicare ID - Type Unspecified