Provider Demographics
NPI:1386696888
Name:LISA C MOORE MD INC
Entity type:Organization
Organization Name:LISA C MOORE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN & PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-453-3312
Mailing Address - Street 1:2461 SANTA MONICA BLVD
Mailing Address - Street 2:#336
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-453-3312
Mailing Address - Fax:310-453-3808
Practice Address - Street 1:1301 20TH ST
Practice Address - Street 2:#290
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-453-3312
Practice Address - Fax:310-453-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71398207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18079Medicare ID - Type Unspecified
I19369Medicare UPIN