Healthcare Provider Details

I. General information

NPI: 1992780597
Provider Name (Legal Business Name): RANDALL JAY MOORE M.D., M.P.H., C.P.E
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366MDG/SGPF 90 HOPE DRIVE; BLDG 6000
MOUNTAIN HOME AFB ID
83648
US

IV. Provider business mailing address

PO BOX 1338
MCCALL ID
83638-1338
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7401
  • Fax:
Mailing address:
  • Phone: 808-772-0871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number4463
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number17958
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberM-4332
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: