Healthcare Provider Details

I. General information

NPI: 1023683760
Provider Name (Legal Business Name): MICHAEL M MOORE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 MAHANEY AVE
TAHLEQUAH OK
74464-5794
US

IV. Provider business mailing address

1519 NORTHPARK DR
TAHLEQUAH OK
74464-6240
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-5115
  • Fax:
Mailing address:
  • Phone: 405-802-2086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6041
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200994650A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: