Provider Demographics
NPI:1467891028
Name:MOORE, KENDALL DEE (MD)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:DEE
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 1:1147 NW 64TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4218
Mailing Address - Country:US
Mailing Address - Phone:352-333-5159
Mailing Address - Fax:
Practice Address - Street 1:8475 NW 39TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-5635
Practice Address - Country:US
Practice Address - Phone:352-627-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132778390200000X, 207P00000X
FLTRN 19026207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115899700Medicaid
FL021400900Medicaid