Provider Demographics
NPI:1124097415
Name:MOORE, THOMAS L (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
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:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-755-3781
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:106 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6019
Practice Address - Country:US
Practice Address - Phone:207-777-8850
Practice Address - Fax:207-777-8641
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD16954208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1673Medicare ID - Type Unspecified
F76870Medicare UPIN