Provider Demographics
NPI:1801058821
Name:MOORE, CHARLES ROBERT (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
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 1:139 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1303
Mailing Address - Country:US
Mailing Address - Phone:601-450-2417
Mailing Address - Fax:601-450-2434
Practice Address - Street 1:139 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1303
Practice Address - Country:US
Practice Address - Phone:601-450-2417
Practice Address - Fax:601-450-2434
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN#12298390200000X
MS20677208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05137554Medicaid
MS05137554Medicaid