Provider Demographics
NPI:1922047646
Name:MOORE, BRADLEY TODD (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TODD
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MAILSTOP 400
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:816-502-8755
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:STE 530
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-932-2836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113158208600000X
KS0429748208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1922047646Medicaid
MOW19B743Medicare PIN
MOH59007Medicare UPIN
KSW19B743AMedicare PIN