Healthcare Provider Details

I. General information

NPI: 1013115476
Provider Name (Legal Business Name): JENNIFER I MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CROSS ST SUITE 300
NORWALK CT
06851-4647
US

IV. Provider business mailing address

40 CROSS ST SUITE 300
NORWALK CT
06851-4647
US

V. Phone/Fax

Practice location:
  • Phone: 203-229-2000
  • Fax: 203-840-9001
Mailing address:
  • Phone: 203-229-2000
  • Fax: 203-840-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number045613
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: