Provider Demographics
NPI:1912048992
Name:MOORE, CHRISTOPHER BRYAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:BRYAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5850 US ROUTE 60
Mailing Address - Street 2:SUITE O
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102-9516
Mailing Address - Country:US
Mailing Address - Phone:606-928-4900
Mailing Address - Fax:606-928-4923
Practice Address - Street 1:5850 US ROUTE 60
Practice Address - Street 2:SUITE O
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9516
Practice Address - Country:US
Practice Address - Phone:606-928-4900
Practice Address - Fax:606-928-4923
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00273213E00000X, 213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000216342OtherANTHEM BC AND BS
KY371421256OtherTAX IDENTIFICATION NUMBER
KY7774351OtherAETNA US HEALTHCARE
KYU80502Medicare UPIN
KY2018301Medicare ID - Type Unspecified