Provider Demographics
NPI:1568552644
Name:MOORE, COURTENAY K (MD)
Entity Type:Individual
Prefix:
First Name:COURTENAY
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-8155
Mailing Address - Fax:614-293-3565
Practice Address - Street 1:915 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3153
Practice Address - Country:US
Practice Address - Phone:614-293-8155
Practice Address - Fax:614-293-3565
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35085038207VF0040X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2583575Medicaid
OH7351701Medicare PIN
OH2583575Medicaid