MEDICARE: SUSAN S 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
1	208000000X	Pediatrics Physician	ME92420	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316035413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN S MOORE MD

Provider Business Mailing Address
First Line	:	5396 HIDDEN GARDENS DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-4201
Country	:	US
Telephone Number	:	904-553-4644
Fax Number	:

Provider Business Practice Location Address
First Line	:	6271 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2523
Country	:	US
Telephone Number	:	904-633-0460
Fax Number	:	904-633-0461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	12/27/2011

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Directions to “ SUSAN S MOORE MD” Practice Location

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