Healthcare Provider Details

I. General information

NPI: 1962484204
Provider Name (Legal Business Name): JOHN C. MOAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7835 PARAGON ROAD
DAYTON OH
45459
US

IV. Provider business mailing address

7835 PARAGON ROAD
DAYTON OH
45459-4021
US

V. Phone/Fax

Practice location:
  • Phone: 937-434-2351
  • Fax: 937-434-1266
Mailing address:
  • Phone: 937-434-2351
  • Fax: 937-434-1266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberOH35076460
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: