Basic Information
| Provider Information | |||||||||
| NPI: | 1073562476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 E. HWY 90 | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205197720 | ||||||||
| FaxNumber: | 5205195181 | ||||||||
| Practice Location | |||||||||
| Address1: | 5151 E. HWY 90 | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208036644 | ||||||||
| FaxNumber: | 5205442943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | 10112 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 237851 | 05 | AZ | MEDICAID |