Provider Demographics
NPI:1780769489
Name:MOORE, DARLENE A
Entity type:Individual
Prefix:
First Name:DARLENE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-756-6751
Mailing Address - Fax:573-756-1965
Practice Address - Street 1:1103 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-756-6751
Practice Address - Fax:573-756-1965
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6D31208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209703016Medicaid
MO026012642Medicare ID - Type Unspecified
MO209703016Medicaid