Provider Demographics
NPI:1063723260
Name:IRVINE-MOORE, LAPONNA RAE (DO)
Entity type:Individual
Prefix:
First Name:LAPONNA
Middle Name:RAE
Last Name:IRVINE-MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAPONNA
Other - Middle Name:RAE
Other - Last Name:IRVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5701 BRYANT IRVIN RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4029
Mailing Address - Country:US
Mailing Address - Phone:817-361-5037
Mailing Address - Fax:817-361-5031
Practice Address - Street 1:5701 BRYANT IRVIN RD
Practice Address - Street 2:SUITE 304
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4029
Practice Address - Country:US
Practice Address - Phone:817-361-5037
Practice Address - Fax:817-361-5031
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BN848OtherBCBSTX
TX217337901Medicaid
TX8BN848OtherBCBSTX