Provider Demographics
NPI:1962418459
Name:MOORE, ANNIE ANDERSON (MD, MBA)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:ANDERSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD, MBA
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:MCMINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MBA
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:WISH CLINIC, UNIVERSITY OF COLORADO HOSPITAL
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13905207R00000X
CODR.0054340207R00000X
NC2012-00846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR153783Medicaid
OR153783Medicaid