Provider Demographics
NPI:1528647955
Name:MOORE, MATTHEW MACAHAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MACAHAN
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 1:1001 HIGHWAY 578
Mailing Address - Street 2:
Mailing Address - City:EAST BERNSTADT
Mailing Address - State:KY
Mailing Address - Zip Code:40729-7216
Mailing Address - Country:US
Mailing Address - Phone:606-231-7510
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-04
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332962-01208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics