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General NPI Number Information
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NPI Number | 1720208242
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Entity Type | Organization
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Legal Business Name | O FRED MOORE III MD PC
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 503 TICKLE STREET
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City | DYERSBURG
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State | TN
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Zip | 38024
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Country | US
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Telephone | 731-285-5244
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Fax | 731-285-5244
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Provider Business Mailing Address
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Address Line | 503 TICKLE STREET
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City | DYERSBURG
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State | TN
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Zip | 38024
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Country | US
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Telephone | 731-285-5244
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Fax | 731-285-8970
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Authorized Official
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Title or Position | PRESIDENT OF CORPORATION
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Name | OLYN FRED MOORE III
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Credential | MD
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Telephone | 731-285-5244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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