Provider Demographics
NPI:1043272339
Name:MOORE, REGINALD G (MD)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:G
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 1:121 49TH AVENUE PL NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-9349
Mailing Address - Country:US
Mailing Address - Phone:828-381-3636
Mailing Address - Fax:828-728-2030
Practice Address - Street 1:121 49TH AVENUE PL NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-9349
Practice Address - Country:US
Practice Address - Phone:828-381-3636
Practice Address - Fax:828-728-2030
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23064207Q00000X
GA19853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891144EMedicaid
NC2220075YMedicare ID - Type Unspecified
NC891144EMedicaid