Basic Information
| Provider Information | |||||||||
| NPI: | 1831144005 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 ALVARADO RD | ||||||||
| Address2: | #108 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194602770 | ||||||||
| FaxNumber: | 6194602774 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 GROSSMONT CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197404000 | ||||||||
| FaxNumber: | 6197404207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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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 | 2085R0202X | G683360 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | G68336 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | G68336 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G683360 | 05 | CA | MEDICAID | 00G683360 | 01 | CA | BLUE SHIELD PIN | OTHER | 10963841 | 01 | CAQH | OTHER |