Provider Demographics
NPI:1699732339
Name:MOORE, ANGELA A (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:A
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 1:3612 SOUTHLINKS CV.
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125
Mailing Address - Country:US
Mailing Address - Phone:901-748-1819
Mailing Address - Fax:
Practice Address - Street 1:3612 SOUTHLINKS CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-0758
Practice Address - Country:US
Practice Address - Phone:901-748-1819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36780A208D00000X
TN367802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3878150Medicaid
H73364Medicare UPIN
3878150Medicare ID - Type Unspecified