MEDICARE: JOHN WILLIAM MOORE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9801401	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1166L	OTHER	NC	BC BS NC

General Provider Information

NPI Number	:	1235163668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WILLIAM MOORE D.O.

Provider Business Mailing Address
First Line	:	4049 MAIN ST
Second Line	:
City	:	CHINCOTEAGUE ISLAND
State	:	VA
Zip	:	23336-2406
Country	:	US
Telephone Number	:	704-942-5603
Fax Number	:

Provider Business Practice Location Address
First Line	:	4049 MAIN ST
Second Line	:
City	:	CHINCOTEAGUE ISLAND
State	:	VA
Zip	:	23336-2406
Country	:	US
Telephone Number	:	757-336-3682
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	02/23/2021

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