Basic Information
| Provider Information | |||||||||
| NPI: | 1568557577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | WYLIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13811 MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774774903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137721200 | ||||||||
| FaxNumber: | 2814910426 | ||||||||
| Practice Location | |||||||||
| Address1: | 16651 SOUTHWEST FWY | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774792345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137721200 | ||||||||
| FaxNumber: | 2814910426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | J4371 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 20033056 | 01 | TX | MEDICARE RR | OTHER | 5834481 | 01 | TX | AETNA | OTHER | 10018768 | 01 | TX | AMERIGROUP | OTHER | 3974024 | 01 | TX | CIGNA | OTHER | 0479214-01 | 05 | TX | MEDICAID |