Provider Demographics
NPI:1548351000
Name:MOY, MARIE A (DO)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:MOY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2252
Mailing Address - Country:US
Mailing Address - Phone:414-258-9511
Mailing Address - Fax:414-607-3946
Practice Address - Street 1:1509 WILSON TERRACE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:909-469-6741
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A77872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG1263OtherRAILROAD MEDICARE
CA00AX77870Medicaid
P01045170OtherRR MEDICARE
CA1548351000Medicaid
CACG1263OtherRAILROAD MEDICARE
CAAO679LMedicare PIN
CA1548351000Medicaid