Provider Demographics
NPI:1679620082
Name:MOORE, JOSEPH TODD (FNP, DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:TODD
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19594 STATE HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:IL
Mailing Address - Zip Code:62860-1127
Mailing Address - Country:US
Mailing Address - Phone:618-435-3960
Mailing Address - Fax:618-435-2478
Practice Address - Street 1:11 EXECUTIVE WOODS CT
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2016
Practice Address - Country:US
Practice Address - Phone:618-513-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027238363LF0000X
MO2023010527363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU48965Medicare UPIN