Provider Demographics
NPI:1619173838
Name:MOORE, JACQUELINE DIANA (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANA
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 1:24560 SOUTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3510
Mailing Address - Country:US
Mailing Address - Phone:703-258-0399
Mailing Address - Fax:
Practice Address - Street 1:24560 SOUTHPOINT DR
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-3510
Practice Address - Country:US
Practice Address - Phone:703-258-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2120208600000X
VA0101270338208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN