Provider Demographics
NPI:1033405220
Name:MOORE, DEREK CECIL (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:CECIL
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:156 SOMERSET LN APT 12
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-3210
Mailing Address - Country:US
Mailing Address - Phone:620-845-0116
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-827-5566
Practice Address - Fax:440-827-5573
Is Sole Proprietor?:No
Enumeration Date:2011-06-26
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS05-37542207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine