Provider Demographics
NPI:1811987993
Name:MOORE, DOUGLAS K (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:K
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12931 BRIGHTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:317-574-0104
Mailing Address - Fax:317-573-7098
Practice Address - Street 1:13420 N MERIDIAN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1581
Practice Address - Country:US
Practice Address - Phone:317-573-7050
Practice Address - Fax:317-573-7098
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026319A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100381620Medicaid
IN100381620Medicaid
IN677690DDDMedicare PIN
IND94959Medicare UPIN
IN318860CMedicare ID - Type Unspecified