Healthcare Provider Details

I. General information

NPI: 1164857512
Provider Name (Legal Business Name): MOORE OBGYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6196 OXON HILL RD STE 610
OXON HILL MD
20745-3112
US

IV. Provider business mailing address

7610 PENNSYLVANIA AVE SUITE 305
FORESTVILLE MD
20747-4701
US

V. Phone/Fax

Practice location:
  • Phone: 301-669-1870
  • Fax: 301-669-1873
Mailing address:
  • Phone: 301-669-1870
  • Fax: 301-669-1873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAVAKA MOORE
Title or Position: CHIEF EXECUTIVE MANAGER
Credential: M.D.
Phone: 301-669-1870