Provider Demographics
NPI:1427073469
Name:MOORE, DONALD R (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:130 TOWN CENTER DR
Mailing Address - Street 2:STE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:586-445-2330
Mailing Address - Fax:586-445-2352
Practice Address - Street 1:25599 KELLY RD
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4975
Practice Address - Country:US
Practice Address - Phone:586-445-2330
Practice Address - Fax:586-445-2352
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-10-22
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Provider Licenses
StateLicense IDTaxonomies
MIDM038055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3232662Medicaid
MIDM038055OtherSTATE LICENSE
110131072OtherRAILROAD MEDICARE
MI1105016431OtherBLUE CROSS BLUE SHIELD
B48181Medicare UPIN
MI3232662Medicaid