Provider Demographics
NPI:1417788126
Name:MOORE, ROBERT WADE
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WADE
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74131-4427
Mailing Address - Country:US
Mailing Address - Phone:918-407-8030
Mailing Address - Fax:
Practice Address - Street 1:4915 W 84TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74131-4427
Practice Address - Country:US
Practice Address - Phone:918-407-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist