Provider Demographics
NPI:1144260688
Name:MOORE, SANDRA VELIA (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:VELIA
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-0368
Mailing Address - Country:US
Mailing Address - Phone:214-923-1705
Mailing Address - Fax:972-442-9958
Practice Address - Street 1:5106 RAVENSTHORPE DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:TX
Practice Address - Zip Code:75002-5496
Practice Address - Country:US
Practice Address - Phone:214-923-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1836208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135460705Medicaid
TXC19510Medicare UPIN