Provider Demographics
NPI:1861607194
Name:MOORE, VICKIE S (MD)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:815 EAST PARKWAY
Mailing Address - Street 2:SUITE #7
Mailing Address - City:GATLINBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37738-4915
Mailing Address - Country:US
Mailing Address - Phone:865-436-2811
Mailing Address - Fax:865-436-2812
Practice Address - Street 1:815 EAST PARKWAY
Practice Address - Street 2:SUITE #7
Practice Address - City:GATLINBURG
Practice Address - State:TN
Practice Address - Zip Code:37738-4915
Practice Address - Country:US
Practice Address - Phone:865-436-2811
Practice Address - Fax:865-436-2812
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000014031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4378288OtherAETNA
TN0072043OtherBCBS
TN7068691OtherCIGNA
TN0072043OtherBCBS
TNB04728Medicare UPIN