Provider Demographics
NPI:1235170812
Name:MOORE, JACK W (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4715 WHITESBURG DR S
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1632
Mailing Address - Country:US
Mailing Address - Phone:256-881-5151
Mailing Address - Fax:256-880-3939
Practice Address - Street 1:4715 WHITESBURG DR S
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1632
Practice Address - Country:US
Practice Address - Phone:256-881-5151
Practice Address - Fax:256-880-3939
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL21750207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG77252Medicare UPIN