Provider Demographics
NPI:1063670602
Name:MOORE, JONATHAN M (DPM)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:32743 23 MILE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2176
Mailing Address - Country:US
Mailing Address - Phone:708-424-3201
Mailing Address - Fax:708-424-5001
Practice Address - Street 1:3248 WESTBOURNE DR STE 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-5146
Practice Address - Country:US
Practice Address - Phone:513-662-3900
Practice Address - Fax:513-662-3933
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH36003490213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00702222OtherRAILROAD MEDICARE
OH2859741Medicaid
OHP01130203OtherRAILROAD MEDICARE PIN
OH6355840001Medicare NSC
OH4240581Medicare PIN
OH4240582Medicare PIN
OHP00702222OtherRAILROAD MEDICARE
OHP01130203OtherRAILROAD MEDICARE PIN