Healthcare Provider Details

I. General information

NPI: 1235240185
Provider Name (Legal Business Name): MICHAEL J MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 N 51ST ST
OMAHA NE
68132-2867
US

IV. Provider business mailing address

2500 CALIFORNIA PLZ
OMAHA NE
68178-0001
US

V. Phone/Fax

Practice location:
  • Phone: 402-449-5959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19541
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: