Provider Demographics
NPI:1952667735
Name:MOREN, ANDREW DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVIS
Last Name:MOREN
Suffix:
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 1:1 KETTERING WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-4109
Mailing Address - Country:US
Mailing Address - Phone:937-914-7179
Mailing Address - Fax:937-522-9960
Practice Address - Street 1:2115 LEITER RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3659
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6939
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35126069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0137920Medicaid
OHH366090Medicare PIN
OH0137920Medicaid