Provider Demographics
NPI:1093393373
Name:MOORE, MIKAELA D (MD)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 W LEXINGTON STE 100
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3667
Mailing Address - Country:US
Mailing Address - Phone:513-977-6700
Mailing Address - Fax:
Practice Address - Street 1:1775 W LEXINGTON STE 100
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-3667
Practice Address - Country:US
Practice Address - Phone:513-977-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
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