Provider Demographics
NPI:1841215225
Name:MOORE, RAYMOND MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R.
Other - Middle Name:MICHAEL
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:280 VA AVENUE NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1539
Mailing Address - Country:US
Mailing Address - Phone:276-679-2555
Mailing Address - Fax:276-679-2680
Practice Address - Street 1:280 VA AVENUE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1539
Practice Address - Country:US
Practice Address - Phone:276-679-2555
Practice Address - Fax:276-679-2680
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00065331OtherRAILROAD MEDICARE
VA000101600OtherFEDERAL BLACK LUNG
VA258965OtherANTHEM BLUE CROSS/SHIELD
VA005612713Medicaid
VA080007990Medicare ID - Type Unspecified
VA005612713Medicaid