Provider Demographics
NPI:1265727556
Name:MOORE, NICHOLAS JAY (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:26850 PROVIDENCE PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1256
Mailing Address - Country:US
Mailing Address - Phone:248-465-5140
Mailing Address - Fax:248-465-5141
Practice Address - Street 1:26850 PROVIDENCE PKWY STE 260
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1256
Practice Address - Country:US
Practice Address - Phone:248-465-5140
Practice Address - Fax:248-465-5141
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301108292207Q00000X, 207QS0010X
CT053150390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program