MEDICARE: DR. JOHN T MOORE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	2004005496	MO
2	207R00000X	Internal Medicine Physician	2004005496	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356399323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN T MOORE MD

Provider Business Mailing Address
First Line	:	454 W JACKSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-3647
Country	:	US
Telephone Number	:	636-485-1524
Fax Number	:	314-461-6518

Provider Business Practice Location Address
First Line	:	2905 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2713
Country	:	US
Telephone Number	:	636-464-9333
Fax Number	:	314-461-6518

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	12/17/2024

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Directions to “ DR. JOHN T MOORE MD” Practice Location

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