Provider Demographics
NPI:1063954238
Name:MOORE, MEGAN (MS RD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MERCED ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4201
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 MERCED ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1029039OtherCOMMISSION ON DIETETIC REGISTRATION