Provider Demographics
NPI:1992743850
Name:MOORE, FREDERICK A (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:352-273-5670
Mailing Address - Fax:352-273-5683
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-5670
Practice Address - Fax:352-273-5683
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF98472086S0102X
FLME1103102086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003839400Medicaid
TX136971210Medicaid
TXP00345039OtherRAILROAD MEDICARE
TX136971211OtherCSHCN
TX8V8609OtherBLUE CROSS BLUE SHIELD
TX8V8609OtherBLUE CROSS BLUE SHIELD
TXD24326Medicare UPIN
FL003839400Medicaid