Provider Demographics
NPI:1326002023
Name:MOORE, PAUL E (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:E
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 1:471 KLUTEY PARK PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-3347
Mailing Address - Country:US
Mailing Address - Phone:270-830-6100
Mailing Address - Fax:270-826-3089
Practice Address - Street 1:110 3RD ST STE 250
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-5802
Practice Address - Country:US
Practice Address - Phone:270-826-0135
Practice Address - Fax:270-827-8798
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64223936Medicaid
000000062228OtherANTHEM
000000062228OtherANTHEM
KY0255516Medicare ID - Type UnspecifiedKY MCR
IN532500JJMedicare ID - Type UnspecifiedIN MCR
KY64223936Medicaid