Provider Demographics
NPI:1578626305
Name:MOORE, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
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:DEPT 557
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-0001
Mailing Address - Country:US
Mailing Address - Phone:303-467-4162
Mailing Address - Fax:303-318-2488
Practice Address - Street 1:1960 OGDEN ST
Practice Address - Street 2:SUITE 530
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1022
Practice Address - Country:US
Practice Address - Phone:303-318-2600
Practice Address - Fax:303-318-2604
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25670208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01256700Medicaid
COC807432Medicare PIN
CO01256700Medicaid
COC807433Medicare PIN