Provider Demographics
NPI:1740384817
Name:MOORE, KAREN STACY (MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:STACY
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:STACY
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:COTTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35453-0104
Mailing Address - Country:US
Mailing Address - Phone:205-535-0325
Mailing Address - Fax:205-632-5150
Practice Address - Street 1:5717 BRADFORD LN
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-5680
Practice Address - Country:US
Practice Address - Phone:205-535-0325
Practice Address - Fax:507-607-8721
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009912061Medicaid
AL051517128Medicaid
AL051517128OtherBCBS
AL051517128OtherBCBS
G12128Medicare UPIN
051517128Medicare ID - Type Unspecified