Provider Demographics
NPI:1235541350
Name:MOORE, RYAN (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:20 PROSPECT AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1941
Mailing Address - Country:US
Mailing Address - Phone:551-996-4371
Mailing Address - Fax:
Practice Address - Street 1:20 PROSPECT AVE STE 404
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1941
Practice Address - Country:US
Practice Address - Phone:551-996-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10834500208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery