Provider Demographics
NPI:1104978238
Name:MOORE, RODERICK ALAN (DPM)
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:ALAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 140TH AVE NE
Mailing Address - Street 2:UNIT 201
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-6928
Mailing Address - Country:US
Mailing Address - Phone:425-481-7055
Mailing Address - Fax:
Practice Address - Street 1:17000 140TH AVE NE
Practice Address - Street 2:UNIT 201
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-6928
Practice Address - Country:US
Practice Address - Phone:425-481-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000305213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1018365Medicaid
WAT03035Medicare UPIN
WA0487040001Medicare NSC