Provider Demographics
NPI:1801894662
Name:MOORE, M KENT (MD)
Entity type:Individual
Prefix:DR
First Name:M
Middle Name:KENT
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:564 W 9TH PL
Mailing Address - Street 2:STE 3
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-4069
Mailing Address - Country:US
Mailing Address - Phone:480-834-3868
Mailing Address - Fax:480-833-0763
Practice Address - Street 1:564 W 9TH PL
Practice Address - Street 2:STE 3
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-4069
Practice Address - Country:US
Practice Address - Phone:480-834-3868
Practice Address - Fax:480-833-0763
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ8097207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0377870OtherBCBS
4654696OtherAETNA
AZ120367OtherHEALTHNET
AZZMD8097Medicare ID - Type Unspecified
4654696OtherAETNA