=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750104337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY MOORE MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3130 SW 89TH ST STE 200
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-7909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-645-5475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1637 NW 12TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73106-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-645-5475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------