Healthcare Provider Details

I. General information

NPI: 1467411645
Provider Name (Legal Business Name): CRAIG BEATY MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NORTH BROADWAY
HOBART OK
73651
US

IV. Provider business mailing address

125 NORTH BROADWAY
HOBART OK
73651
US

V. Phone/Fax

Practice location:
  • Phone: 580-726-5653
  • Fax: 580-726-3661
Mailing address:
  • Phone: 580-726-5653
  • Fax: 580-726-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11960
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: