Provider Demographics
NPI:1316049158
Name:MOORE, DONNA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2528 WHEATON WAY #206
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3305
Mailing Address - Country:US
Mailing Address - Phone:360-373-8272
Mailing Address - Fax:360-373-7054
Practice Address - Street 1:2528 WHEATON WAY #206
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3305
Practice Address - Country:US
Practice Address - Phone:360-373-8272
Practice Address - Fax:360-373-7054
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00024149208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1100692Medicaid
WAE70372Medicare UPIN