Provider Demographics
NPI:1548766363
Name:MOORE, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 SANCTUARY DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-8816
Mailing Address - Country:US
Mailing Address - Phone:586-354-3681
Mailing Address - Fax:
Practice Address - Street 1:6252 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2003
Practice Address - Country:US
Practice Address - Phone:240-686-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014984207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program