Provider Demographics
NPI:1730147497
Name:MOORE, TIM J (MD)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 GUSDORF RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:575-758-5001
Mailing Address - Fax:575-737-5046
Practice Address - Street 1:1329 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-5001
Practice Address - Fax:575-737-5046
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0111207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3125165Medicaid
NM60122838Medicaid
MA3125165Medicaid
NMNM300652Medicare PIN
J14611Medicare ID - Type Unspecified