Healthcare Provider Details

I. General information

NPI: 1982973137
Provider Name (Legal Business Name): CANDACE MAKEDA MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 AVE LAGUNA APT 8H CON. LAUNA GARDENS; APT. 8H
CAROLINA PR
00979-6574
US

IV. Provider business mailing address

4 AVE. LAGUNA; APT 8H CON. LAUNA GARDENS; APT. 8H
CAROLINA PR
00979
US

V. Phone/Fax

Practice location:
  • Phone: 979-579-3402
  • Fax:
Mailing address:
  • Phone: 979-579-3402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number13058-I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: