MEDICARE: DONALD HALSTEAD MOORE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	13276	WV
2	207Q00000X	Family Medicine Physician	13276	WV

General Provider Information

NPI Number	:	1235133562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD HALSTEAD MOORE MD

Provider Business Mailing Address
First Line	:	4605 MACCORKLE AVE SW
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1311
Country	:	US
Telephone Number	:	304-414-4800
Fax Number	:	304-414-4801

Provider Business Practice Location Address
First Line	:	1097 FLEDDERJOHN RD STE 1
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-4208
Country	:	US
Telephone Number	:	304-345-3627
Fax Number	:	304-346-4440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/08/2021

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Directions to “ DONALD HALSTEAD MOORE MD” Practice Location

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