Healthcare Provider Details

I. General information

NPI: 1245596022
Provider Name (Legal Business Name): JEREMY MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

1 WYOMING ST
DAYTON OH
45409-2722
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-3356
  • Fax: 937-208-3356
Mailing address:
  • Phone: 937-208-3356
  • Fax: 937-208-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.122401
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: