Provider Demographics
NPI:1265424048
Name:MOORE, HEATHER M (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15455 NW GREENBRIER PKWY
Mailing Address - Street 2:STE 112
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7374
Mailing Address - Country:US
Mailing Address - Phone:503-466-1668
Mailing Address - Fax:503-439-6194
Practice Address - Street 1:15455 NW GREENBRIER PKWY
Practice Address - Street 2:STE 111
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7374
Practice Address - Country:US
Practice Address - Phone:503-531-3434
Practice Address - Fax:503-645-4544
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071592Medicaid
OR071592Medicaid
105282Medicare ID - Type Unspecified