Provider Demographics
NPI:1467426221
Name:MOORE, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
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 418283
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8283
Mailing Address - Country:US
Mailing Address - Phone:202-877-6034
Mailing Address - Fax:202-877-8329
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-877-6034
Practice Address - Fax:202-877-8329
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD19916174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC025615700Medicaid
MD042931700Medicaid
VA5817889Medicaid
DC015572YT2Medicare PIN
MD042931700Medicaid
DC015572YT2Medicare PIN
DCF65447Medicare UPIN