Provider Demographics
NPI:1386647972
Name:MOORE, GARY RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RANDALL
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 1:515 READ ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1739
Mailing Address - Country:US
Mailing Address - Phone:812-424-9291
Mailing Address - Fax:812-421-2722
Practice Address - Street 1:515 READ ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1739
Practice Address - Country:US
Practice Address - Phone:812-424-9291
Practice Address - Fax:812-421-2722
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030659A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100179870Medicaid
IN000000067659OtherANTHEM BCBS
IN0231480001OtherMEDICARE DME
INC69458Medicare UPIN
IN847950GMedicare ID - Type Unspecified