Provider Demographics
NPI:1720029911
Name:MOORE, DAVID K (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:K
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E COUNTY LINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1070
Practice Address - Country:US
Practice Address - Phone:317-885-2860
Practice Address - Fax:317-885-2869
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003501A207R00000X, 208M00000X
MO2007022729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000612728OtherANTHEM
IN200938600Medicaid
INP00730628OtherMEDICARE RR
INP00730628OtherMEDICARE RR
IN070860C7Medicare PIN