Provider Demographics
NPI:1316962582
Name:MOORE, ERIC A (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
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 1:424 TIMBERWALK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4027
Mailing Address - Country:US
Mailing Address - Phone:407-496-3549
Mailing Address - Fax:407-878-4406
Practice Address - Street 1:424 TIMBERWALK LN
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4027
Practice Address - Country:US
Practice Address - Phone:407-496-3549
Practice Address - Fax:407-878-4406
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1617532012OtherCIGNA
FL25666OtherBLUE CROSS BLUE SHIELD
FL7726099OtherAETNA PPO/POS
FL3104492OtherAETNA HMO
FL261403100Medicaid
FL25666OtherBLUE CROSS BLUE SHIELD
FL3104492OtherAETNA HMO