Provider Demographics
NPI:1619323946
Name:MOORE, JUSTIN DERRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DERRICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:DERRICK
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5268 LYND AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1031
Mailing Address - Country:US
Mailing Address - Phone:810-223-1330
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE # 44195
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-2648
Practice Address - Country:US
Practice Address - Phone:810-223-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139964207VM0101X, 207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology