Provider Demographics
NPI:1750342531
Name:MOORE, JESSE DANIEL (MD)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:DANIEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:400 HIGHWAY 64 E
Mailing Address - Street 2:PO BOX 497
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-5150
Mailing Address - Country:US
Mailing Address - Phone:870-347-3300
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:606 W WILBUR MILLS AVE
Practice Address - Street 2:
Practice Address - City:KENSETT
Practice Address - State:AR
Practice Address - Zip Code:72082-9051
Practice Address - Country:US
Practice Address - Phone:501-742-5697
Practice Address - Fax:870-347-3492
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARE0005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126445001Medicaid
AR126445001Medicaid
AR5J3237297Medicare PIN
F74938Medicare UPIN
AR5J323Medicare PIN