Healthcare Provider Details

I. General information

NPI: 1770581019
Provider Name (Legal Business Name): MARY ANN DEVLIN MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 04/19/2020
Certification Date: 04/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 DORCHESTER AVE
CAMBRIDGE MD
21613-2420
US

IV. Provider business mailing address

300 DORCHESTER AVE
CAMBRIDGE MD
21613-2420
US

V. Phone/Fax

Practice location:
  • Phone: 410-228-2603
  • Fax: 410-901-6080
Mailing address:
  • Phone: 410-228-2603
  • Fax: 410-901-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0031766
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: