Healthcare Provider Details

I. General information

NPI: 1356399323
Provider Name (Legal Business Name): JOHN T MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAY T MOORE MD

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 S BRENTWOOD BLVD
SAINT LOUIS MO
63144-2713
US

IV. Provider business mailing address

454 W JACKSON RD
SAINT LOUIS MO
63119-3647
US

V. Phone/Fax

Practice location:
  • Phone: 636-464-9333
  • Fax: 314-461-6518
Mailing address:
  • Phone: 636-485-1524
  • Fax: 314-461-6518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004005496
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2004005496
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: