Provider Demographics
NPI:1053376350
Name:MOO, JEFFREY BARD (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BARD
Last Name:MOO
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 1:16529 9TH PL NW
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-3723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 E JEFFERSON ST
Practice Address - Street 2:SUITE 600
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5698
Practice Address - Country:US
Practice Address - Phone:206-320-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA27908208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1111038Medicaid
WA130982OtherLABOR & INDUSTRIES NUMBER
WA130982OtherLABOR & INDUSTRIES NUMBER
WAF36404Medicare UPIN
WAAB13988Medicare PIN