Healthcare Provider Details

I. General information

NPI: 1619323946
Provider Name (Legal Business Name): JUSTIN DERRICK MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUSTIN DERRICK MOORE M.D

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W BOWERY ST STE 5
AKRON OH
44308-1069
US

IV. Provider business mailing address

2178 EDGEVIEW DR
HUDSON OH
44236-1825
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-4500
  • Fax:
Mailing address:
  • Phone: 810-223-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35.139964
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number35.139964
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: