Provider Demographics
NPI:1487918413
Name:MOORE, ROBERT WALLACE JR (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WALLACE
Last Name:MOORE
Suffix:JR
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 1:4563 LANDFALL CT
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5313
Mailing Address - Country:US
Mailing Address - Phone:850-650-5784
Mailing Address - Fax:
Practice Address - Street 1:4563 LANDFALL CT
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5313
Practice Address - Country:US
Practice Address - Phone:850-650-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6287207X00000X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma