Provider Demographics
NPI:1114039237
Name:MOORE, GERALD L (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
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:PO BOX 5638
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40255-0638
Mailing Address - Country:US
Mailing Address - Phone:502-363-1312
Mailing Address - Fax:
Practice Address - Street 1:2020 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1803
Practice Address - Country:US
Practice Address - Phone:502-479-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY141002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200389000 AMedicaid
KY64-141005Medicaid
KY64-141005Medicaid
IN200389000 AMedicaid