Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 101756 | NY |
NPI | 1205130176 |
---|---|
Provider Name | Dr. John Robert Moore |
First Address | Remsen, NY 13438-4621 |
Second Address | Remsen, NY 13438-4621 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/01/2011 |
Last Update Date | 06/01/2011 |