Basic Information
| Provider Information | |||||||||
| NPI: | 1598736696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | WELLER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | HQ MEDDAC B | ||||||||
| Address2: | UNIT 28037 BLDG 700 | ||||||||
| City: | APO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 09112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145902368 | ||||||||
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| Practice Location | |||||||||
| Address1: | HQ MEDDACB | ||||||||
| Address2: | UNIT 28037 BLDG 700 | ||||||||
| City: | APO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 09112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145902368 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33155 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 331554 | 05 | SC | MEDICAID |