Healthcare Provider Details

I. General information

NPI: 1871888545
Provider Name (Legal Business Name): MILTON RAHMON MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 BROADWAY ST STE 201N
SAN ANTONIO TX
78215-1145
US

IV. Provider business mailing address

1314 E SONTERRA BLVD STE 2201
SAN ANTONIO TX
78258-4287
US

V. Phone/Fax

Practice location:
  • Phone: 210-226-0040
  • Fax: 210-226-0050
Mailing address:
  • Phone: 210-496-5792
  • Fax: 210-496-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10039988
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberP5691
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: