Provider Demographics
NPI:1831170919
Name:MOORE, DONALD WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WILSON
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-7000
Mailing Address - Fax:
Practice Address - Street 1:401 W DECATUR ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NC
Practice Address - Zip Code:27025-1913
Practice Address - Country:US
Practice Address - Phone:336-548-9618
Practice Address - Fax:336-548-4877
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831170919OtherBLUE MEDICARE
NC1831170919OtherHUMANA
NC1831170919OtherAETNA
NC1831170919OtherNC BLUE CROSS
NC202297DOtherMEDICARE
NC8960207Medicaid
NC1831170919OtherUNITED HEALTHCARE
NC1831170919OtherCOVENTRY
NC1831170919OtherCOMMERCIAL
NC1831170919OtherAARP MEDICARE COMPLETE