Provider Demographics
NPI:1255316915
Name:MOORE, JEFFREY LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3234
Mailing Address - Country:US
Mailing Address - Phone:704-654-5443
Mailing Address - Fax:
Practice Address - Street 1:135 N EWING ST
Practice Address - Street 2:SUITE 301
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3382
Practice Address - Country:US
Practice Address - Phone:740-654-3668
Practice Address - Fax:740-654-7528
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2397-M213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0654377Medicaid
OH0654377Medicaid
OHT80673Medicare UPIN
OH0599664Medicare PIN