Healthcare Provider Details

I. General information

NPI: 1245425982
Provider Name (Legal Business Name): JAY WINSTON MOORE PH.D., FACMG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10421 UNIVERSITY CENTER DR STE. 100
TAMPA FL
33612-6427
US

IV. Provider business mailing address

10421 UNIVERSITY CENTER DR STE. 100
TAMPA FL
33612-6427
US

V. Phone/Fax

Practice location:
  • Phone: 813-615-4362
  • Fax: 813-972-4632
Mailing address:
  • Phone: 813-615-4362
  • Fax: 813-972-4632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License NumberDI38149
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License NumberMOORJ1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: