Healthcare Provider Details

I. General information

NPI: 1831144005
Provider Name (Legal Business Name): BRIAN S MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

7777 ALVARADO RD #108
LA MESA CA
91942
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4000
  • Fax: 619-740-4207
Mailing address:
  • Phone: 619-460-2770
  • Fax: 619-460-2774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG683360
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG68336
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG68336
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: