Healthcare Provider Details

I. General information

NPI: 1841281276
Provider Name (Legal Business Name): ROBERT L MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 OLD CANTON RD
JACKSON MS
39211-4217
US

IV. Provider business mailing address

5604 OLD CANTON RD
JACKSON MS
39211-4217
US

V. Phone/Fax

Practice location:
  • Phone: 601-991-1044
  • Fax: 601-991-9868
Mailing address:
  • Phone: 601-991-1044
  • Fax: 601-991-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18036
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: