Healthcare Provider Details

I. General information

NPI: 1013992247
Provider Name (Legal Business Name): THOMAS K MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 COOLIDGE RD
EAST LANSING MI
48823-1378
US

IV. Provider business mailing address

2001 COOLIDGE RD
EAST LANSING MI
48823-1378
US

V. Phone/Fax

Practice location:
  • Phone: 517-337-1668
  • Fax: 517-337-1779
Mailing address:
  • Phone: 517-337-1668
  • Fax: 517-337-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301047643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: