Healthcare Provider Details

I. General information

NPI: 1467426221
Provider Name (Legal Business Name): JACK MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

PO BOX 418283
BOSTON MA
02241-8283
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-6034
  • Fax: 202-877-8329
Mailing address:
  • Phone: 202-877-6034
  • Fax: 202-877-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD19916
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD19916
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: