Provider Demographics
NPI:1235163668
Name:MOORE, JOHN WILLIAM (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHINCOTEAGUE ISLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23336-2406
Mailing Address - Country:US
Mailing Address - Phone:704-942-5603
Mailing Address - Fax:
Practice Address - Street 1:4049 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHINCOTEAGUE ISLAND
Practice Address - State:VA
Practice Address - Zip Code:23336-2406
Practice Address - Country:US
Practice Address - Phone:757-336-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343893AMedicaid
NC891166LMedicaid
NC1166LOtherBC BS NC
NCNCA602AMedicare UPIN
NCE07298Medicare UPIN
NC2253295EMedicare PIN
NC891166LMedicaid
NC343893AMedicaid