Provider Demographics
NPI:1750547360
Name:MOORE, MARKEITA R (MD)
Entity type:Individual
Prefix:DR
First Name:MARKEITA
Middle Name:R
Last Name:MOORE
Suffix:
Gender:
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:9730 S WESTERN AVE STE 500
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2780
Practice Address - Country:US
Practice Address - Phone:708-425-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13157-320208000000X
IL036.127687208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100306967Medicaid