Healthcare Provider Details

I. General information

NPI: 1548248552
Provider Name (Legal Business Name): BRIAN ANDREW MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD SUITE 114
EGLIN AFB FL
32542-1391
US

IV. Provider business mailing address

307 BOATNER RD SUITE 114
EGLIN AFB FL
32542-1391
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8264
  • Fax: 850-883-8253
Mailing address:
  • Phone: 850-883-8264
  • Fax: 850-883-8253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberL7051
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMD.200570
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: