Provider Demographics
NPI:1265676274
Name:MOORE, JEREMY PAUL (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:PAUL
Last Name:MOORE
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-825-5296
Mailing Address - Fax:310-825-9524
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:B265
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-0867
Practice Address - Fax:310-825-9524
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88084208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265676274OtherCCS PANELED
CA00A880840Medicaid
CA1265676274Medicaid
CA1265676274OtherCCS PANELED
CADA038XMedicare PIN