Provider Demographics
NPI:1124005210
Name:MOORE, JEFFREY LEE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
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 1:3428 W MARKET ST
Mailing Address - Street 2:STE 103
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3339
Mailing Address - Country:US
Mailing Address - Phone:330-344-3583
Mailing Address - Fax:330-869-2074
Practice Address - Street 1:400 WABASH AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2433
Practice Address - Country:US
Practice Address - Phone:330-344-6525
Practice Address - Fax:330-996-2943
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0534782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0628744Medicaid
OH1144401464OtherPRACTICE LOCATION NPI GROUP NUMBER
OH9338635OtherMEDICARE GROUP NUMBER
OH2774985OtherMEDICAID GROUP NUMBER
OH1841239274OtherMEDICARE NPI GROUP NUMBER
M 0584773Medicare ID - Type Unspecified
OH1841239274OtherMEDICARE NPI GROUP NUMBER
OH0584776Medicare PIN