Provider Demographics
NPI:1306819917
Name:MOORE, JOHN STEVEN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEVEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:STEVEN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:200 MELVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-6609
Mailing Address - Country:US
Mailing Address - Phone:405-238-5555
Mailing Address - Fax:405-238-6348
Practice Address - Street 1:200 MELVILLE DR
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-6609
Practice Address - Country:US
Practice Address - Phone:405-238-5555
Practice Address - Fax:405-238-6348
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2388207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100100420AMedicaid
OK100100420AMedicaid