Provider Demographics
NPI:1386801710
Name:MOORE, LISA C (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1301 20TH STREET
Mailing Address - Street 2:STE 100
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2208
Mailing Address - Country:US
Mailing Address - Phone:310-829-4528
Mailing Address - Fax:310-453-2161
Practice Address - Street 1:250 N ROBERTSON BLVD STE 606
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1793
Practice Address - Country:US
Practice Address - Phone:310-423-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71398207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA71398AMedicare PIN
CAI19369Medicare UPIN