Healthcare Provider Details

I. General information

NPI: 1013379429
Provider Name (Legal Business Name): CAROL E MOORE MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828B MAPLEWOOD AVE
WINSTON SALEM NC
27103-4138
US

IV. Provider business mailing address

2828B MAPLEWOOD AVE
WINSTON SALEM NC
27103-4138
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-9440
  • Fax:
Mailing address:
  • Phone: 336-659-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number34108
License Number StateNC

VIII. Authorized Official

Name: CAROL MOORE
Title or Position: DIRECTOR
Credential: MD
Phone: 336-659-9440