Healthcare Provider Details

I. General information

NPI: 1720794167
Provider Name (Legal Business Name): JOHN R MOORE APRN. CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MACOMB ST
MONROE MI
48162-7815
US

IV. Provider business mailing address

7012 CLOISTER RD
TOLEDO OH
43617-2208
US

V. Phone/Fax

Practice location:
  • Phone: 419-708-8228
  • Fax:
Mailing address:
  • Phone: 419-708-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number0032642
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0032642
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: