Provider Demographics
NPI:1780691246
Name:MOORE, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-226-0112
Mailing Address - Fax:515-226-0208
Practice Address - Street 1:119 19TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4226
Practice Address - Country:US
Practice Address - Phone:515-226-0112
Practice Address - Fax:515-226-0208
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-25520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13285Medicare ID - Type Unspecified
IAA03170Medicare UPIN
IA1039859Medicaid