Provider Demographics
NPI:1740326289
Name:MOORE, KELLEY K (MD)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4851 INDEPENDENCE ST.
Mailing Address - Street 2:70 EXECUTIVE CENTER
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033
Mailing Address - Country:US
Mailing Address - Phone:303-432-5101
Mailing Address - Fax:303-432-5071
Practice Address - Street 1:4851 INDEPENDENCE ST.
Practice Address - Street 2:70 EXECUTIVE CENTER
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6715
Practice Address - Country:US
Practice Address - Phone:303-432-5101
Practice Address - Fax:303-432-5071
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-12-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO328062084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC805239Medicare PIN
COF75575Medicare UPIN