Provider Demographics
NPI:1790727741
Name:MOORE, ANGELA R (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4071 TATES CREEK CENTRE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3062
Mailing Address - Country:US
Mailing Address - Phone:859-260-4385
Mailing Address - Fax:859-260-4386
Practice Address - Street 1:1760 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 401
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1471
Practice Address - Country:US
Practice Address - Phone:859-260-6537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY312162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64312168Medicaid
0508511Medicare ID - Type Unspecified
KY64312168Medicaid