Provider Demographics
NPI:1053346817
Name:MOORE, PHILIP ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1600 LANCASTER DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 LANCASTER DR
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3579
Practice Address - Country:US
Practice Address - Phone:817-488-5170
Practice Address - Fax:817-488-6270
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1835208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C19544Medicare UPIN