Basic Information
| Provider Information | |||||||||
| NPI: | 1881648624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | TOMMY | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Practice Location | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | F4304 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | F4304 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | F4304 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | F4304 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | F4304 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | F4304 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | F4304 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 132698505 | 05 | TX | MEDICAID |