Provider Demographics
NPI:1588640569
Name:MOORE, JERRY W (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials: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 1:1246 ASHLAND AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701
Mailing Address - Country:US
Mailing Address - Phone:740-454-7725
Mailing Address - Fax:740-454-7728
Practice Address - Street 1:1246 ASHLAND AVE
Practice Address - Street 2:STE 107
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701
Practice Address - Country:US
Practice Address - Phone:740-454-7725
Practice Address - Fax:740-454-7728
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35043340M207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0426239Medicaid
OH0426239Medicaid
OHMO0437415Medicare PIN
OH4280781Medicare PIN