Provider Demographics
NPI:1548235898
Name:MOORE, JOHN MALCOLM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MALCOLM
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 1:1300 CENTERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4349
Mailing Address - Country:US
Mailing Address - Phone:501-219-8900
Mailing Address - Fax:501-537-1875
Practice Address - Street 1:1300 CENTERVIEW DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4349
Practice Address - Country:US
Practice Address - Phone:501-219-8900
Practice Address - Fax:501-537-1875
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC3170208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D79829Medicare UPIN
53741Medicare ID - Type Unspecified