Provider Demographics
NPI:1679519367
Name:MOORE, RICHARD E (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-377-0777
Mailing Address - Fax:208-377-1070
Practice Address - Street 1:6156 W EMERALD STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8613
Practice Address - Country:US
Practice Address - Phone:208-377-0777
Practice Address - Fax:208-377-1070
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5456207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0347440001Medicare NSC
ID002676100Medicaid
IDD93353Medicare UPIN
ID1121872Medicare ID - Type Unspecified