Provider Demographics
NPI:1194801373
Name:MOORE, WILLIAM DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:DAVID
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1127 N WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1164
Mailing Address - Country:US
Mailing Address - Phone:765-662-4666
Mailing Address - Fax:765-662-4106
Practice Address - Street 1:1127 N WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1164
Practice Address - Country:US
Practice Address - Phone:765-662-4666
Practice Address - Fax:765-662-4106
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043323A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100465860BMedicaid
INA46791Medicare UPIN
IN160550Medicare ID - Type UnspecifiedMEDICARE NUMBER