Healthcare Provider Details

I. General information

NPI: 1609296623
Provider Name (Legal Business Name): ERIC MOORE MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

30 N 1900 E RM 4C116 UNIVERSITY OF UTAH DEPT OF MEDICINE OFFICE OF EDUCATION
SALT LAKE CITY UT
84132-2101
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-4384
  • Fax:
Mailing address:
  • Phone: 801-581-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9538427-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: