Provider Demographics
NPI:1528157468
Name:MOORE, MARITA L (MD)
Entity type:Individual
Prefix:
First Name:MARITA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 W MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2060
Mailing Address - Country:US
Mailing Address - Phone:220-564-4824
Mailing Address - Fax:220-564-1896
Practice Address - Street 1:1272 W MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2060
Practice Address - Country:US
Practice Address - Phone:220-564-4824
Practice Address - Fax:220-564-1896
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36336207Q00000X
IL036-098387207Q00000X
OH35.094506207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3049883Medicaid
IA0473009Medicaid
IAH56547Medicare UPIN
OHH240157Medicare PIN
OH3049883Medicaid