Provider Demographics
NPI:1992780597
Name:MOORE, RANDALL JAY (MD, MPH, CPE)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD, MPH, CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-1338
Mailing Address - Country:US
Mailing Address - Phone:808-772-0871
Mailing Address - Fax:
Practice Address - Street 1:366MDG/SGPF
Practice Address - Street 2:90 HOPE DRIVE; BLDG 6000
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:208-828-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT44632083A0100X
AZ179582083A0100X
IDM-43322083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine