Provider Demographics
NPI:1285425561
Name:MOORE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LIBERTY SQ STE 2078
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5800
Mailing Address - Country:US
Mailing Address - Phone:617-581-8063
Mailing Address - Fax:
Practice Address - Street 1:86 ORMOND ST # LL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-1508
Practice Address - Country:US
Practice Address - Phone:617-581-8063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier