Healthcare Provider Details

I. General information

NPI: 1548231053
Provider Name (Legal Business Name): CHIMER D MOORE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 VIRGINIA AVENUE
WYTHEVILLE VA
24382
US

IV. Provider business mailing address

360 VIRGINIA AVENUE
WYTHEVILLE VA
24382
US

V. Phone/Fax

Practice location:
  • Phone: 276-228-2191
  • Fax: 276-228-2801
Mailing address:
  • Phone: 276-228-2191
  • Fax: 276-228-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101012583
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: