Provider Demographics
NPI:1558116087
Name:MOORE, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
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 1:3008 SUDBURY DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1129
Mailing Address - Country:US
Mailing Address - Phone:937-668-6633
Mailing Address - Fax:
Practice Address - Street 1:3008 SUDBURY DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420-1129
Practice Address - Country:US
Practice Address - Phone:937-668-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist