Provider Demographics
NPI:1932595154
Name:MOORE, KEVIN A (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
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 1:2449 HOSPITAL DR STE 440
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-1918
Mailing Address - Country:US
Mailing Address - Phone:318-212-7288
Mailing Address - Fax:318-212-7295
Practice Address - Street 1:2449 HOSPITAL DR STE 440
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-1918
Practice Address - Country:US
Practice Address - Phone:318-212-7288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA306537207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty