Provider Demographics
NPI:1306064860
Name:MOORE, MICHAEL KIRK JR (MD, PC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KIRK
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1769
Mailing Address - Country:US
Mailing Address - Phone:208-552-1406
Mailing Address - Fax:208-552-1416
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 213
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-552-1406
Practice Address - Fax:208-552-1416
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-82702086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-8270OtherMEDICAL LICENSE, ID
UT5959620-1205OtherUT MEDICAL LICENSE
WY58MKM02OtherWY ST BOARD OF PHARMACY
UT5959620-8905OtherUT ST BOARD OF PHARMACY
WY6687AOtherWY MEDICAL LICENSE
IDCS9201OtherID ST BOARD OF PHARMACY
IDCS9201OtherID ST BOARD OF PHARMACY
ID1101834Medicare ID - Type Unspecified
WY6687AOtherWY MEDICAL LICENSE