Provider Demographics
NPI:1366521759
Name:MOORE, MICHAEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5792 WIDEWATERS PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1847
Mailing Address - Country:US
Mailing Address - Phone:315-422-4412
Mailing Address - Fax:
Practice Address - Street 1:5792 WIDEWATERS PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1847
Practice Address - Country:US
Practice Address - Phone:315-422-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85428207W00000X
NY207748207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7429234OtherAETNA
CA90121857OtherPACIFICARE
CA1392936OtherGREAT WEST
CA1767577OtherUNITED HEALTHCARE
CA2258848OtherFIRST HEALTH
CA937998OtherFIRST HEALTH
CA000001620745OtherPHCS
CA49516OtherINTERPLAN
CA089071OtherHEALTH NET
CA2700475OtherCIGNA
CA00G854280Medicaid
NY01852235Medicaid
CAG85428OtherBLUE CROSS
CAMCMG170200OtherWESTERN HEALTH ADVANTAGE
CA00G854280OtherBLUE SHIELD
CA90121857OtherPACIFICARE