Basic Information
| Provider Information | |||||||||
| NPI: | 1750342531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 HIGHWAY 64 E | ||||||||
| Address2: | PO BOX 497 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720065150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703473300 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 W WILBUR MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KENSETT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720829051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017425697 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E0005 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 126445001 | 05 | AR | MEDICAID |