Healthcare Provider Details

I. General information

NPI: 1326021841
Provider Name (Legal Business Name): WALTER PARKER MOORE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 9TH ST
BISMARCK ND
58501-4530
US

IV. Provider business mailing address

401 N 9TH ST
BISMARCK ND
58501-4530
US

V. Phone/Fax

Practice location:
  • Phone: 701-712-4500
  • Fax:
Mailing address:
  • Phone: 701-712-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberH6450
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: