Provider Demographics
NPI:1316681216
Name:MOORE, ELIZABETH WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:WILSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:44250 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1002
Mailing Address - Country:US
Mailing Address - Phone:248-964-0958
Mailing Address - Fax:
Practice Address - Street 1:44250 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1002
Practice Address - Country:US
Practice Address - Phone:248-964-0958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine