Provider Demographics
NPI:1265533046
Name:MOORE, GLEN L (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:113 GAINSBOROUGH SQ
Mailing Address - Street 2:STE 400
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1713
Mailing Address - Country:US
Mailing Address - Phone:757-842-4499
Mailing Address - Fax:757-842-1447
Practice Address - Street 1:113 GAINSBOROUGH SQ
Practice Address - Street 2:STE 400
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1713
Practice Address - Country:US
Practice Address - Phone:757-842-4499
Practice Address - Fax:757-842-1447
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-05-28
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Provider Licenses
StateLicense IDTaxonomies
VA0101044198208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH81011Medicare UPIN
VAMC10328Medicare PIN
GC1014Medicare PIN