Provider Demographics
NPI:1992903769
Name:MOORE, BLAKE WALTER (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:WALTER
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 1:9101 STONY POINT DR.
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235
Mailing Address - Country:US
Mailing Address - Phone:804-330-9105
Mailing Address - Fax:804-287-6119
Practice Address - Street 1:9101 STONY POINT DR.
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-330-9105
Practice Address - Fax:804-287-6119
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256077208800000X
PAMD448758208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992903769OtherHEALTH NET FEDERAL SERVICES
VA1992903769OtherVA HEALTH NETWORK
VA1992903769Medicaid
VA1992903769OtherHUMANA CHOICE CARE
VA1992903769OtherANTHEM BCBS VA
VA1992903769OtherOPTIMA
VA1992903769OtherSOUTHERN HEALTHCARE/COVENTRY
VA5604405OtherCIGNA
VA7505953OtherAETNA
VA1992903769OtherVA PREMIER
VAVVE324AMedicare UPIN
VA1992903769Medicaid