Provider Demographics
NPI:1265079222
Name:MOORE, ANTHONY DUANE JR
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DUANE
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2620
Mailing Address - Country:US
Mailing Address - Phone:937-328-5300
Mailing Address - Fax:937-322-4900
Practice Address - Street 1:2624 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2620
Practice Address - Country:US
Practice Address - Phone:937-328-5300
Practice Address - Fax:937-322-4900
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172686171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator