Healthcare Provider Details

I. General information

NPI: 1508065244
Provider Name (Legal Business Name): JACOB ANDREW MOORE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N LEE AVE SUITE 300
OKLAHOMA CITY OK
73103-2600
US

IV. Provider business mailing address

PO BOX 268986
OKLAHOMA CITY OK
73126-8986
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-7005
  • Fax: 405-272-7391
Mailing address:
  • Phone: 405-231-3857
  • Fax: 405-272-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4541
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: