Provider Demographics
NPI:1457845547
Name:MOORE, ILYSSA PAIGE (MD)
Entity Type:Individual
Prefix:
First Name:ILYSSA
Middle Name:PAIGE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E UNIVERSITY PKWY
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-554-2782
Mailing Address - Fax:443-444-3430
Practice Address - Street 1:201 E UNIVERSITY PKWY
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-554-2782
Practice Address - Fax:443-444-3430
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD95255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program