Provider Demographics
NPI:1902867104
Name:MOORE, BEATRICE LAURIE (MD)
Entity Type:Individual
Prefix:DR
First Name:BEATRICE
Middle Name:LAURIE
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 1:12720 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3325
Mailing Address - Country:US
Mailing Address - Phone:301-646-4177
Mailing Address - Fax:
Practice Address - Street 1:5502 BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3904
Practice Address - Country:US
Practice Address - Phone:703-642-8306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101262282208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL9910903Medicaid