Provider Demographics
NPI:1841281276
Name:MOORE, ROBERT L (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4217
Mailing Address - Country:US
Mailing Address - Phone:601-991-1044
Mailing Address - Fax:601-991-9868
Practice Address - Street 1:5604 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4217
Practice Address - Country:US
Practice Address - Phone:601-991-1044
Practice Address - Fax:601-991-9868
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04133520Medicaid
MS315954200OtherDOL FECA PROVIDER #
MS080003732Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MS6728080001Medicare NSC
MS04133520Medicaid