Provider Demographics
NPI:1124064423
Name:MOORE, TIMOTHY RICHARD (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W FORT ST # 111
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST.
Practice Address - Street 2:#111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12911207RI0011X, 207RC0000X
TXM0189207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1785628Medicaid
TX8J8852Medicare PIN
TXI39936Medicare UPIN
TXP00451644Medicare PIN
TX8F0986Medicare PIN
TX8P9158OtherBLUE CROSS