Provider Demographics
NPI:1770581019
Name:MOORE, MARY ANN DEVLIN (MD)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:DEVLIN
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 1:300 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-2420
Mailing Address - Country:US
Mailing Address - Phone:410-228-2603
Mailing Address - Fax:410-901-6080
Practice Address - Street 1:300 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2420
Practice Address - Country:US
Practice Address - Phone:410-228-2603
Practice Address - Fax:410-901-6080
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407811000Medicaid
MD242M-322FMedicare ID - Type Unspecified
MD407811000Medicaid