Basic Information
Provider Information | |||||||||
NPI: | 1932519188 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | BLAINE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 620 JOHN PAUL JONES CIR | ||||||||
Address2: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
City: | PORTSMOUTH | ||||||||
State: | VA | ||||||||
PostalCode: | 23708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7579531043 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 620 JOHN PAUL JONES CIR | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | VA | ||||||||
PostalCode: | 237082111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7579531043 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2014 | ||||||||
LastUpdateDate: | 01/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | 01076297A | IN | N |   | Other Service Providers | Military Health Care Provider |   | 207R00000X | 01076297A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RH0003X | 01076297A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.