Basic Information
| Provider Information | |||||||||
| NPI: | 1760593230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1911 N FAIRFIELD RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454322762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374294369 | ||||||||
| FaxNumber: | 9374294575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1911 N FAIRFIELD RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454322762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374294369 | ||||||||
| FaxNumber: | 9374294575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/13/2013 | ||||||||
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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 | 35055799M | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2060101 | 01 | UHC | OTHER | 000000281392 | 01 | ANTHEM | OTHER | 0671983 | 05 | OH | MEDICAID |