Healthcare Provider Details

I. General information

NPI: 1366493405
Provider Name (Legal Business Name): JEFFREY E. MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 DAMASCUS RD SUITE A
MARYSVILLE OH
43040-8507
US

IV. Provider business mailing address

200 BRADENTON AVE
DUBLIN OH
43017-7515
US

V. Phone/Fax

Practice location:
  • Phone: 937-578-4040
  • Fax: 937-578-2602
Mailing address:
  • Phone: 614-793-1980
  • Fax: 614-793-1985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-05-3824
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: