Provider Demographics
NPI:1295961233
Name:GREGORY TODD MOORE, DO PA
Entity type:Organization
Organization Name:GREGORY TODD MOORE, DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:KISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-529-1900
Mailing Address - Street 1:2901 ACME BRICK PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4124
Mailing Address - Country:US
Mailing Address - Phone:817-529-1900
Mailing Address - Fax:817-529-1910
Practice Address - Street 1:1320 US-287
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-968-5806
Practice Address - Fax:915-703-7745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0287207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty