Provider Demographics
NPI:1730449489
Name:MOORE, LATASHA D (MD)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:D
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 1:2601 BLAIRSTONE RD STE GC3
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32399-6563
Mailing Address - Country:US
Mailing Address - Phone:850-385-0144
Mailing Address - Fax:
Practice Address - Street 1:2601 BLAIRSTONE RD STE GC3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32399-6563
Practice Address - Country:US
Practice Address - Phone:850-385-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME129044207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018087900Medicaid
FLIQ794ZMedicare PIN