Basic Information
| Provider Information | |||||||||
| NPI: | 1578626305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 557 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802910001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034674162 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 OGDEN ST | ||||||||
| Address2: | SUITE 530 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033182600 | ||||||||
| FaxNumber: | 3033182604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25670 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01256700 | 05 | CO | MEDICAID |