Provider Demographics
NPI:1033320338
Name:MOORE, MATTHEW JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9825 KENWOOD RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6251
Mailing Address - Country:US
Mailing Address - Phone:513-872-4500
Mailing Address - Fax:513-872-4518
Practice Address - Street 1:9825 KENWOOD RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6251
Practice Address - Country:US
Practice Address - Phone:513-872-4500
Practice Address - Fax:513-872-4518
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350840162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100059820Medicaid
OH2885338Medicaid
IN200924180Medicaid
OH4248182Medicare PIN
OH2885338Medicaid