Provider Demographics
NPI:1730264037
Name:MOORE, JAMES LAYNE (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E APPLE ST
Mailing Address - Street 2:SUITE 5254
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-4200
Mailing Address - Fax:937-208-4205
Practice Address - Street 1:300 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6319
Practice Address - Country:US
Practice Address - Phone:507-333-3300
Practice Address - Fax:507-333-3387
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350576772084N0400X, 2084N0600X, 2084S0012X
MN350682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0764605Medicaid
OHH253440Medicare PIN
OHE76680Medicare UPIN
OH0764605Medicaid