Provider Demographics
NPI:1871172635
Name:MOORE, RANDY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
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 1:2849 KENDALE DR APT 202
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3449
Mailing Address - Country:US
Mailing Address - Phone:614-419-2978
Mailing Address - Fax:
Practice Address - Street 1:214 W BOWERY ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1046
Practice Address - Country:US
Practice Address - Phone:330-543-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program