Provider Demographics
NPI:1538194899
Name:MOORE, ROBERT LEE III (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:MOORE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1141 PEAR TREE LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6484
Mailing Address - Country:US
Mailing Address - Phone:707-254-1778
Mailing Address - Fax:707-251-2993
Practice Address - Street 1:1141 PEAR TREE LN
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6484
Practice Address - Country:US
Practice Address - Phone:707-254-1770
Practice Address - Fax:707-251-2993
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG77613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G0776130Medicaid
00G776130Medicare ID - Type Unspecified
CA00G0776130Medicaid