1790812816 NPI number — DR. DEAN L MOORE DPM

Table of content: DR. DEAN L MOORE DPM (NPI 1790812816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790812816 NPI number — DR. DEAN L MOORE DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
DEAN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790812816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 COSTA PACIFICA WAY
Provider Second Line Business Mailing Address:
UNIT 2213
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92054-2195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-633-8584
Provider Business Mailing Address Fax Number:
760-231-9135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16633 DALLAS PKWY
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
ADDISON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75001-6816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-633-8584
Provider Business Practice Location Address Fax Number:
760-231-9135
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  1700 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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