Provider Demographics
NPI:1053373589
Name:MOORE, JULIE A (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W NORTH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1603
Mailing Address - Country:US
Mailing Address - Phone:708-450-5086
Mailing Address - Fax:
Practice Address - Street 1:501 W NORTH AVE STE 103
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1603
Practice Address - Country:US
Practice Address - Phone:708-450-5086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075509207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075509Medicaid
ILK38816Medicare PIN
ILK05937Medicare PIN
IL036075509Medicaid
ILK20056Medicare PIN