Provider Demographics
NPI:1356399323
Name:MOORE, JOHN T (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:T
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:454 W JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3647
Mailing Address - Country:US
Mailing Address - Phone:636-485-1524
Mailing Address - Fax:314-461-6518
Practice Address - Street 1:2905 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2713
Practice Address - Country:US
Practice Address - Phone:636-464-9333
Practice Address - Fax:314-461-6518
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004005496208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208738401Medicaid
MOI09701Medicare UPIN
MO208738401Medicaid