Provider Demographics
NPI:1952489692
Name:MOORE, CHARLES D (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
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 1:6296 CANARY LN
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:CA
Mailing Address - Zip Code:95623-4968
Mailing Address - Country:US
Mailing Address - Phone:916-296-3529
Mailing Address - Fax:
Practice Address - Street 1:6296 CANARY LN
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:CA
Practice Address - Zip Code:95623-4968
Practice Address - Country:US
Practice Address - Phone:916-296-3529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42921207R00000X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A429210Medicaid
00A429210Medicare ID - Type Unspecified
CA00A429210Medicaid