=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700918455
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY SCRANTON MOORE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 EUREKA RD
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-784-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 PARKVIEW DR
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-784-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G054567
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------