Provider Demographics
NPI:1760593230
Name:MOORE, MATTHEW D (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
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 1:1911 N FAIRFIELD RD
Mailing Address - Street 2:STE 110
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2762
Mailing Address - Country:US
Mailing Address - Phone:937-429-4369
Mailing Address - Fax:937-429-4575
Practice Address - Street 1:1911 N FAIRFIELD RD
Practice Address - Street 2:STE 110
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2762
Practice Address - Country:US
Practice Address - Phone:937-429-4369
Practice Address - Fax:937-429-4575
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35055799M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2060101OtherUHC
000000281392OtherANTHEM
OH0671983Medicaid
OH0601804Medicare PIN
OH0601803Medicare PIN