Provider Demographics
NPI:1730602806
Name:MOORE, SIMONE SHARDAE WILLIAMS (MD)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:SHARDAE WILLIAMS
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:SHARDAE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8880
Mailing Address - Fax:
Practice Address - Street 1:702 MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9314
Practice Address - Country:US
Practice Address - Phone:662-741-8800
Practice Address - Fax:662-741-2700
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS27978208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04501349Medicaid