Provider Demographics
NPI:1154339661
Name:MOORE, MATHEW DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-2724
Mailing Address - Country:US
Mailing Address - Phone:928-524-1900
Mailing Address - Fax:
Practice Address - Street 1:500 E FLORIDA ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-2724
Practice Address - Country:US
Practice Address - Phone:928-524-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5746AZ111N00000X
COCHR4245111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ963414Medicaid
AZP00244481OtherRAILROAD MEDICARE
AZAZ0944980OtherBLUE CROSS BLUE SHIELD
AZ963414Medicaid
AZ104836Medicare PIN