Provider Demographics
NPI:1235339870
Name:MOORE, JUSTIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2687
Mailing Address - Country:US
Mailing Address - Phone:937-523-4147
Mailing Address - Fax:937-523-4952
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2687
Practice Address - Country:US
Practice Address - Phone:937-523-4147
Practice Address - Fax:937-523-4952
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.127204207RC0200X, 207RC0200X
NV17941207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094481Medicaid