Provider Demographics
NPI:1457465429
Name:MOORE, MARK S (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
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 7693
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0693
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-342-2093
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-557-4000
Practice Address - Fax:970-342-2093
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1122402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
100180650BOtherOK CAID
100343220AOtherKS CAID
CO83787844Medicaid
451258OtherHLTLINK
115634OtherMO BLUE
MO112240OtherMEDICAL LICENSE
MO248699902Medicaid
MO248699902Medicaid
100343220AOtherKS CAID
MO112240OtherMEDICAL LICENSE