Provider Demographics
NPI:1104354505
Name:MOORE, JOSEPH KALEB
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:KALEB
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 VITALITY DR STE 100A
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-1373
Practice Address - Country:US
Practice Address - Phone:317-621-9220
Practice Address - Fax:317-621-9222
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X
IN01086091A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program