Healthcare Provider Details

I. General information

NPI: 1003893439
Provider Name (Legal Business Name): TIMOTHY A. MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 WALNUT HILL LN
DALLAS TX
75231-4426
US

IV. Provider business mailing address

PO BOX 650426
DALLAS TX
75265-0426
US

V. Phone/Fax

Practice location:
  • Phone: 214-345-6148
  • Fax: 214-345-4322
Mailing address:
  • Phone: 972-715-5007
  • Fax: 972-715-5682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberH0652
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: