Provider Demographics
NPI:1912540857
Name:MOORE, RYAN DAVID (IDMT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MED GROUP, UNIT 3690
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09126
Mailing Address - Country:US
Mailing Address - Phone:314-456-5245
Mailing Address - Fax:
Practice Address - Street 1:SPANGDAHLEM: 52 MED GROUP, UNIT 3690
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126
Practice Address - Country:US
Practice Address - Phone:314-456-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians