Provider Demographics
NPI:1306101571
Name:MOORE, STEVEN SHANE (DPM)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:SHANE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13660 N 94TH DR STE F1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4232
Mailing Address - Country:US
Mailing Address - Phone:623-974-0522
Mailing Address - Fax:623-933-5787
Practice Address - Street 1:13660 N 94TH DR STE F1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4232
Practice Address - Country:US
Practice Address - Phone:623-974-0522
Practice Address - Fax:623-933-5787
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN41000273A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist