Provider Demographics
NPI:1598841322
Name:MOORE, JONATHAN ROSS SR (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROSS
Last Name:MOORE
Suffix:SR
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 1:75 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1730
Mailing Address - Country:US
Mailing Address - Phone:251-479-3309
Mailing Address - Fax:
Practice Address - Street 1:75 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1730
Practice Address - Country:US
Practice Address - Phone:251-479-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL30077208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program