Provider Demographics
NPI:1790762508
Name:MOORE, GRACE D (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:D
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:PO BOX 950251
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0251
Mailing Address - Country:US
Mailing Address - Phone:502-897-9594
Mailing Address - Fax:502-736-4456
Practice Address - Street 1:2307 GREENE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4009
Practice Address - Country:US
Practice Address - Phone:502-897-9594
Practice Address - Fax:502-736-4456
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37065207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200445300OtherMEDICAID
KY64-074552Medicaid
KY0285230Medicare ID - Type Unspecified
IN200445300OtherMEDICAID