Healthcare Provider Details

I. General information

NPI: 1598736696
Provider Name (Legal Business Name): THOMAS WELLER MOORE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 05/12/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HQ MEDDACB UNIT 28037 BLDG 700
APO AE
09112
US

IV. Provider business mailing address

HQ MEDDAC B UNIT 28037 BLDG 700
APO NY
09112
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2368
  • Fax:
Mailing address:
  • Phone: 314-590-2368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33155
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: