Healthcare Provider Details

I. General information

NPI: 1871599282
Provider Name (Legal Business Name): TERESA A.F. MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 KING STREET
KEYSVILLE VA
23947-4540
US

IV. Provider business mailing address

PO BOX 927 5 E ALVON ROAD, SUITE 7
WHITE SULPHUR SPRINGS WV
24986-2373
US

V. Phone/Fax

Practice location:
  • Phone: 434-736-8801
  • Fax: 434-736-0292
Mailing address:
  • Phone: 304-536-5030
  • Fax: 304-536-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101052933
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: