Provider Demographics
NPI:1417905092
Name:MOORE, NICHOLAS JE (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JE
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 KELLY JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3908
Mailing Address - Country:US
Mailing Address - Phone:719-593-1799
Mailing Address - Fax:
Practice Address - Street 1:1390 KELLY JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3908
Practice Address - Country:US
Practice Address - Phone:719-593-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO486642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88639266OtherMEDICAID
COBM7400752OtherDEA