Provider Demographics
NPI:1366408080
Name:MOORE, ROGER T (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:T
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N NAPPANEE STREET
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514
Mailing Address - Country:US
Mailing Address - Phone:574-522-0265
Mailing Address - Fax:574-293-2855
Practice Address - Street 1:111 N NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1957
Practice Address - Country:US
Practice Address - Phone:574-522-0265
Practice Address - Fax:574-293-2855
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058554A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INH80026Medicare UPIN
IN216570AMedicare ID - Type Unspecified