Healthcare Provider Details

I. General information

NPI: 1316035413
Provider Name (Legal Business Name): SUSAN S MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6271 SAINT AUGUSTINE RD
JACKSONVILLE FL
32217-2523
US

IV. Provider business mailing address

5396 HIDDEN GARDENS DR
JACKSONVILLE FL
32258-4201
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0460
  • Fax: 904-633-0461
Mailing address:
  • Phone: 904-553-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME92420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: