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1104111590 NPI number — KEVIN EMMANUAL MOORE D.P.M.

NPI Number: 1104111590
Health Care Provider/Practitioner: KEVIN EMMANUAL MOORE D.P.M.

Information about “1104111590” NPI (KEVIN EMMANUAL MOORE D.P.M.) exists in 1104111590 in HTML format HTML  |  1104111590 in plain Text format TXT  |  1104111590 in PDF (Portable Document Format) PDF  |  1104111590 in an XML format XML  formats.

NPI Number : 1104111590 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1104111590",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MOORE",
    "FirstName": "KEVIN",
    "MiddleName": "EMMANUAL",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "D.P.M.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 6619",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MACON",
    "MailingAddressStateName": "GA",
    "MailingAddressPostalCode": "31208-6619",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "478-333-2430",
    "MailingAddressFaxNumber": "478-333-2173",
    "FirstLinePracticeLocationAddress": "109 OSIGIAN BLVD STE 300",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "WARNER ROBINS",
    "PracticeLocationAddressStateName": "GA",
    "PracticeLocationAddressPostalCode": "31088-8924",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "478-333-2430",
    "PracticeLocationAddressFaxNumber": "478-333-2173",
    "EnumerationDate": "06/14/2011",
    "LastUpdateDate": "02/01/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "213ES0103X",
          "TaxonomyName": "Foot & Ankle Surgery Podiatrist",
          "LicenseNumber": "288",
          "LicenseNumberStateCode": "OK",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "213ES0103X",
          "TaxonomyName": "Foot & Ankle Surgery Podiatrist",
          "LicenseNumber": "POD001181",
          "LicenseNumberStateCode": "GA",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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