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NPI Code Detail

MEDICARE: MARISSA MOORE MD

MEDICARE: MARISSA MOORE MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician333248LA
2207Q00000XFamily Medicine Physician4301514377MI

General Provider Information

NPI Number : 1295297638
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARISSA MOORE MD
Provider Business Mailing Address
First Line : 1 FORD PL STE 3A
Second Line :
City : DETROIT
State : MI
Zip : 48202-3450
Country : US
Telephone Number : 313-874-4806
Fax Number : 313-876-1305
Provider Business Practice Location Address
First Line : 201 SAINT ANN DR STE B
Second Line :
City : MANDEVILLE
State : LA
Zip : 70471-3472
Country : US
Telephone Number : 985-898-4001
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/04/2019
Last Update Date : 09/17/2025

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