Basic Information
| Provider Information | |||||||||
| NPI: | 1932462447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | CASONDRA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 E BELL RD STE 2200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333838 | ||||||||
| FaxNumber: | 6026333845 | ||||||||
| Practice Location | |||||||||
| Address1: | 7330 N 99TH AVE STE 200A | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853073003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234330202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | L2258824 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 007657 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | Z220861 | 01 | AZ | MEDICARE | OTHER | 449626 | 05 | AZ | MEDICAID |