Provider Demographics
NPI:1861587818
Name:MOORE, JOHN E (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2342
Mailing Address - Country:US
Mailing Address - Phone:406-563-4386
Mailing Address - Fax:
Practice Address - Street 1:307 E PARK AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2342
Practice Address - Country:US
Practice Address - Phone:406-563-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7622208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0013889Medicaid
F63501Medicare UPIN
MT000081063Medicare Oscar/Certification