Provider Demographics
NPI:1477609089
Name:MOORE, REBECCA HEROLD (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:HEROLD
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 742382
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1160 E 3900 S STE G200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1224
Practice Address - Country:US
Practice Address - Phone:801-268-7766
Practice Address - Fax:801-270-3395
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO44442207RN0300X
TXN2671207RN0300X
UT7549060207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology