Healthcare Provider Details

I. General information

NPI: 1710068507
Provider Name (Legal Business Name): MICHAEL MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7225 RAINBOW DRIVE
SAN JOSE CA
95129-4552
US

IV. Provider business mailing address

7225 RAINBOW DRIVE MEDICAL STAFF
SAN JOSE CA
95129-0000
US

V. Phone/Fax

Practice location:
  • Phone: 408-739-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG70269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: