Provider Demographics
NPI:1326399478
Name:MOORE, JEFFREY DAVID (DPT)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5005
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-5005
Mailing Address - Country:US
Mailing Address - Phone:719-297-9009
Mailing Address - Fax:719-284-7163
Practice Address - Street 1:700 US HWY 24 S
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211
Practice Address - Country:US
Practice Address - Phone:719-297-9009
Practice Address - Fax:719-284-7163
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0011913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12433208OtherCAQH