Individual
COLLEEN JOHNSON MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
21 DOCTORS PARK STE A, CAPE GIRARDEAU, MO 63703-4927
(217) 788-0706
(217) 525-2535
Mailing address
21 DOCTORS PARK STE A, CAPE GIRARDEAU, MO 63703-4927
(573) 837-4131
(573) 837-4132
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
Primary
036113689
IL
2086S0129X
Vascular Surgery Physician
2004001641
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036113689
—
IL
01
—
F400526418
MEDICARE PIN
IL
Enumeration date
11/07/2005
Last updated
07/27/2023
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