Organization
WEATHERFORD FAMILY PRACTICE MEDICAL CENTER PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TAMALA ROCHELLE MALLETT MOORE M.D. (OWNER/MEDICAL DOCTOR)
(580) 772-2400
Entity
Organization
Contact information
Practice address
3739 LEGACY, WEATHERFORD, OK 73096-9746
(580) 772-2400
(580) 772-2408
Mailing address
3739 LEGACY, WEATHERFORD, OK 73096-9746
(580) 772-2400
(580) 772-2408
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
26755
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200224110A
—
OK
01
—
26755
OKLAHOMA STATE MEDICAL LICENSE
OK
01
—
37994
BNDD
OK
01
—
OKB5382
MEDICARE PTAN
OK
01
—
P00691960
RAIL ROAD MEDICARE PTAN
OK
Enumeration date
12/22/2008
Last updated
01/24/2011
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