Basic Information
| Provider Information | |||||||||
| NPI: | 1992817472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | PHYSICIAN SUPPORT SERVICES - 2ND FL | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 MERCY AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953408368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095643700 | ||||||||
| FaxNumber: | 2095643799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A87523 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.