Provider Demographics
NPI:1245298389
Name:MOORE, DOUGLAS R (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DOUG
Other - Middle Name:R
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 22063
Mailing Address - Street 2:DEPT 0289
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-2063
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:2929 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5101
Practice Address - Country:US
Practice Address - Phone:918-665-1520
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9916207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100116970AMedicaid
OKD35061Medicare UPIN
OK100116970AMedicaid
OK930085758Medicare PIN
OK24H619009Medicare PIN