Provider Demographics
NPI:1306940739
Name:MOORE, KEVIN R (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
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 1:869 E 4500 S
Mailing Address - Street 2:PMB 511
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3049
Mailing Address - Country:US
Mailing Address - Phone:801-487-0451
Mailing Address - Fax:801-487-2467
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT273877-12052085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870355724KRMOtherEDUCATORS MUTUAL
UT35834OtherDESERET MUTUAL
UT83716OtherPUBLIC EMPLOYEES HEALTH
UT107007661103OtherSELECTHEALTH
UT1600788OtherUNITED HEALTHCARE
UT8550895OtherAETNA
UTQM0000027099OtherALTIUS
UT7541OtherUUHN
UT8061904OtherCIGNA
UTF60654Medicare UPIN
UT83716OtherPUBLIC EMPLOYEES HEALTH