Provider Demographics
NPI:1326097494
Name:MOORE, LARRY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ALAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:290 CRYSTAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:MANITOA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829
Mailing Address - Country:US
Mailing Address - Phone:719-651-6070
Mailing Address - Fax:719-686-8863
Practice Address - Street 1:3205 N ACADEMY BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5101
Practice Address - Country:US
Practice Address - Phone:719-776-3216
Practice Address - Fax:719-776-3187
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21039207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42677076Medicaid
CO42677076Medicaid
COCOA110001Medicare PIN