Healthcare Provider Details

I. General information

NPI: 1720021777
Provider Name (Legal Business Name): WALTER SCOTT MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NORTH IH 35 STE 635
AUSTIN TX
78705-1804
US

IV. Provider business mailing address

408 W 45TH ST
AUSTIN TX
78751-3014
US

V. Phone/Fax

Practice location:
  • Phone: 512-320-1500
  • Fax: 512-320-1588
Mailing address:
  • Phone: 512-451-5800
  • Fax: 512-459-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberF5313
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: