Provider Demographics
NPI:1750175212
Name:MOORE, THOMAS
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4230
Mailing Address - Country:US
Mailing Address - Phone:202-679-0909
Mailing Address - Fax:202-679-0909
Practice Address - Street 1:180 BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4230
Practice Address - Country:US
Practice Address - Phone:202-679-0909
Practice Address - Fax:202-679-0909
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-59273175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist