Basic Information
| Provider Information | |||||||||
| NPI: | 1952964249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE SHELBY | ||||||||
| FirstName: | DIAMOND | ||||||||
| MiddleName: | RASHIDA | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | DIAMOND | ||||||||
| OtherMiddleName: | RASHIDA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DRIVE | ||||||||
| Address2: | SUITE J2000 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493447 | ||||||||
| FaxNumber: | 2488498120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S. CANTON CENTER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343987880 | ||||||||
| FaxNumber: | 7347617318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 4301507301 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.