Provider Demographics
NPI:1831170265
Name:MOORE, WILLIAM R (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
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 3799
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043
Mailing Address - Country:US
Mailing Address - Phone:931-245-7092
Mailing Address - Fax:931-245-7069
Practice Address - Street 1:490 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-245-8400
Practice Address - Fax:931-245-8465
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16028208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ004449Medicaid
A98983Medicare UPIN
TN3025929Medicare ID - Type Unspecified