Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Y00000X | Otolaryngologist (ENT Doctor) | L7051 | TX |
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | MD.200570 | LA |
NPI | 1548248552 |
---|---|
Provider Name | Dr. Brian Andrew Moore |
First Address | Eglin Afb, FL 32542-1391 |
Second Address | Eglin Afb, FL 32542-1391 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2006 |
Last Update Date | 03/09/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04630817 | (05) | MS |
1465917 | (05) | LA |
VAD000 | (02) | FL |