Provider Demographics
NPI:1386890572
Name:MOORE, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
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 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3019
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-2519
Practice Address - Street 1:6901 MEDICAL VIEW LANE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-6648
Practice Address - Country:US
Practice Address - Phone:813-788-7867
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94273207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000299400Medicaid
FL000299700Medicaid
FL000299700Medicaid