Provider Demographics
NPI:1104111590
Name:MOORE, KEVIN EMMANUAL (DPM)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EMMANUAL
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
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 6619
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-6619
Mailing Address - Country:US
Mailing Address - Phone:478-333-2430
Mailing Address - Fax:478-333-2173
Practice Address - Street 1:109 OSIGIAN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8924
Practice Address - Country:US
Practice Address - Phone:478-333-2430
Practice Address - Fax:478-333-2173
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK288213ES0103X
GAPOD001181213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116370BMedicaid