Healthcare Provider Details

I. General information

NPI: 1346244837
Provider Name (Legal Business Name): WILLIAM DAVID MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 LYON ST NW STE 700
GRAND RAPIDS MI
49503-2210
US

IV. Provider business mailing address

220 LYON ST NW STE 700
GRAND RAPIDS MI
49503-2210
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-4500
  • Fax: 616-451-9077
Mailing address:
  • Phone: 616-451-4500
  • Fax: 616-451-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301034150
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: