Healthcare Provider Details

I. General information

NPI: 1104853142
Provider Name (Legal Business Name): JOSEPH MICHAEL MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7127 S OLYMPIA AVE
TULSA OK
74132-1856
US

IV. Provider business mailing address

701 CEDAR LAKE BLVD STE 160
OKLAHOMA CITY OK
73114-7818
US

V. Phone/Fax

Practice location:
  • Phone: 918-876-0521
  • Fax: 918-876-0939
Mailing address:
  • Phone: 405-724-0574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23398
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23398
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: