Provider Demographics
NPI:1275570301
Name:MOORE, NATHANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15101 E ILIFF AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-4548
Mailing Address - Country:US
Mailing Address - Phone:720-878-7055
Mailing Address - Fax:720-390-5188
Practice Address - Street 1:895 S LOGAN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209
Practice Address - Country:US
Practice Address - Phone:303-733-3764
Practice Address - Fax:303-733-0868
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO35543207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01355437Medicaid
CO01355437Medicaid
CO517028Medicare ID - Type Unspecified