Provider Demographics
NPI:1609818467
Name:MOORE, ANNETTE M (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-453-8571
Practice Address - Fax:765-453-8637
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056265A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01830736OtherRAIL ROAD PTAN
IN200826150Medicaid
INP01830736OtherRR PTAN
ININ1663003Medicare PIN
IN266180827Medicare PIN
INP01830736OtherRR PTAN