Provider Demographics
NPI:1992753040
Name:MOORE, RICHARD JAY (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAY
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 1:63 BOVET RD
Mailing Address - Street 2:# 406
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3104
Mailing Address - Country:US
Mailing Address - Phone:650-539-4224
Mailing Address - Fax:650-292-2149
Practice Address - Street 1:63 BOVET RD
Practice Address - Street 2:# 406
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3104
Practice Address - Country:US
Practice Address - Phone:650-539-4224
Practice Address - Fax:650-292-2149
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG63467207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG63467OMedicaid
CAF14966Medicare UPIN
CA00G634670Medicare ID - Type UnspecifiedCOUNTY OF SAN FRANCISCO
CA00G634672Medicare ID - Type UnspecifiedSAN MATEO COUNTY