Provider Demographics
NPI:1013941392
Name:MOORE, CHRISTOPHER C (DPM)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:C
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0997
Mailing Address - Country:US
Mailing Address - Phone:618-457-0431
Mailing Address - Fax:618-457-5199
Practice Address - Street 1:1235 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5335
Practice Address - Country:US
Practice Address - Phone:618-457-0431
Practice Address - Fax:618-457-5199
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003389213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03922239OtherBLUE CROSS BLUE SHIELD
ILCI5845 / 1013941392OtherRAILROAD MEDICARE
IL016003389Medicaid
ILT38053Medicare UPIN
IL505620 / L66907Medicare PIN
IL0718600001Medicare NSC
IL03922239OtherBLUE CROSS BLUE SHIELD