Healthcare Provider Details

I. General information

NPI: 1710982640
Provider Name (Legal Business Name): CLEN DAMON MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: C DAMON MOORE MD

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46440 BENEDICT DR STE 207
STERLING VA
20164-6602
US

IV. Provider business mailing address

PO BOX 17334
BALTIMORE MD
21297-1334
US

V. Phone/Fax

Practice location:
  • Phone: 703-444-2100
  • Fax: 703-444-0386
Mailing address:
  • Phone: 703-443-6717
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101056399
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: