Healthcare Provider Details

I. General information

NPI: 1063670602
Provider Name (Legal Business Name): JONATHAN M MOORE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 12/04/2022
Certification Date: 12/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3248 WESTBOURNE DR STE 1
CINCINNATI OH
45248-5146
US

IV. Provider business mailing address

32743 23 MILE RD STE 210
CHESTERFIELD MI
48047-2176
US

V. Phone/Fax

Practice location:
  • Phone: 513-662-3900
  • Fax: 513-662-3933
Mailing address:
  • Phone: 708-424-3201
  • Fax: 708-424-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003490
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: