Healthcare Provider Details

I. General information

NPI: 1902877012
Provider Name (Legal Business Name): CHARLES S MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 STUDT AVE
CREVE COEUR MO
63141-7480
US

IV. Provider business mailing address

11700 STUDT AVE
SAINT LOUIS MO
63141-7480
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-1181
  • Fax: 314-989-1441
Mailing address:
  • Phone: 314-989-1181
  • Fax: 314-989-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013017434
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: