Basic Information
| Provider Information | |||||||||
| NPI: | 1699734418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1727 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815021727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702417600 | ||||||||
| FaxNumber: | 9702634831 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 HORIZON CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815068701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702417600 | ||||||||
| FaxNumber: | 9702634831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20243 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1202431 | 05 | CO | MEDICAID | 20243 | 01 | CO | CO BOARD MEDICAL | OTHER | AM7071133 | 01 | DEA | OTHER |