Provider Demographics
NPI:1699156950
Name:MOORE, LEE ELLIS (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ELLIS
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 1:501 BAPTIST DR STE 220
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-2031
Mailing Address - Country:US
Mailing Address - Phone:601-985-9120
Mailing Address - Fax:
Practice Address - Street 1:501 BAPTIST DR STE 220
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2031
Practice Address - Country:US
Practice Address - Phone:601-985-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC209770207R00000X
OK34523207W00000X
MS27439207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology