Provider Demographics
NPI:1356450043
Name:MOYER, MARY E (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MOYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5385
Mailing Address - Fax:505-552-5828
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5385
Practice Address - Fax:505-552-5828
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
AZUNITED HEALTHCAREOther52-2363606
AZ86-0696633OtherUNITED HEALTH
AZ112590OtherACCHS
AZAZ0325350OtherBLUE CROSS BLUE SHIELD
AZARIZONA FOUNDATIONOther52-2363606
AZC-41006Medicare UPIN
AZAZ0325351OtherNEW BCBS