Provider Demographics
NPI:1336644723
Name:MOORE, JACOB CLARK (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CLARK
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
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 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-3036
Mailing Address - Fax:812-450-2193
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747-0001
Practice Address - Country:US
Practice Address - Phone:812-450-3036
Practice Address - Fax:812-450-2193
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006369A208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program