Provider Demographics
NPI:1548248552
Name:MOORE, BRIAN ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ANDREW
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1391
Mailing Address - Country:US
Mailing Address - Phone:850-883-8264
Mailing Address - Fax:850-883-8253
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:SUITE 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-8264
Practice Address - Fax:850-883-8253
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7051207Y00000X
LAMD.200570207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1465917Medicaid
MS04630817Medicaid
MS04630817Medicaid
FLVAD000Medicare UPIN