Provider Demographics
NPI:1609099100
Name:MOORE, DANIEL BAILEY (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BAILEY
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 1:208 CROSSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1468
Mailing Address - Country:US
Mailing Address - Phone:859-873-8044
Mailing Address - Fax:859-873-8045
Practice Address - Street 1:208 CROSSFIELD DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1468
Practice Address - Country:US
Practice Address - Phone:859-873-8044
Practice Address - Fax:859-873-8045
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02001204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64020019Medicaid
C69521Medicare UPIN
KY64020019Medicaid