Healthcare Provider Details

I. General information

NPI: 1669552030
Provider Name (Legal Business Name): CHRISTOPHER MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

IV. Provider business mailing address

1715 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-8418
  • Fax:
Mailing address:
  • Phone: 904-264-8418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME96662
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: