1699734418 NPI number — THOMAS A MOORE JR. DO

Table of content: THOMAS A MOORE JR. DO (NPI 1699734418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699734418 NPI number — THOMAS A MOORE JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
THOMAS
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699734418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1727
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81502-1727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-241-7600
Provider Business Mailing Address Fax Number:
970-263-4831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
743 HORIZON CT
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81506-8701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-241-7600
Provider Business Practice Location Address Fax Number:
970-263-4831
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20243 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1202431 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20243 . This is a "CO BOARD MEDICAL" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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