Basic Information
| Provider Information | |||||||||
| NPI: | 1316102270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | JELANI | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18840 ROSELAND BLVD | ||||||||
| Address2: | |||||||||
| City: | LATHRUP VILLAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480765913 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST | ||||||||
| Address2: | 9C UHC | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301092753 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.