Provider Demographics
NPI:1801877923
Name:MOORE, COLLEEN JOHNSON (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:JOHNSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLEEN
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:21 DOCTORS PARK STE A
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4927
Mailing Address - Country:US
Mailing Address - Phone:573-837-4131
Mailing Address - Fax:573-837-4132
Practice Address - Street 1:21 DOCTORS PARK STE A
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4927
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040016412086S0129X
IL0361136892086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113689Medicaid
ILF400526418OtherMEDICARE PIN
ILK20639Medicare PIN
IL256510Medicare PIN