Healthcare Provider Details

I. General information

NPI: 1073562476
Provider Name (Legal Business Name): MICHAEL J MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 E. HWY 90
SIERRA VISTA AZ
85635
US

IV. Provider business mailing address

5151 E. HWY 90
SIERRA VISTA AZ
85635
US

V. Phone/Fax

Practice location:
  • Phone: 520-803-6644
  • Fax: 520-544-2943
Mailing address:
  • Phone: 520-519-7720
  • Fax: 520-519-5181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number10112
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: