Provider Demographics
NPI:1528035540
Name:MOE, JOHN GILBERT (PHD, MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GILBERT
Last Name:MOE
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 PARK TER 330
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-9212
Mailing Address - Country:US
Mailing Address - Phone:310-295-2255
Mailing Address - Fax:310-657-4950
Practice Address - Street 1:6801 PARK TER 330
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-9212
Practice Address - Country:US
Practice Address - Phone:310-295-2255
Practice Address - Fax:310-657-4950
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG46368Medicare ID - Type Unspecified
A92643Medicare UPIN