Provider Demographics
NPI:1851954390
Name:MOORE, MARIAH T (MD)
Entity type:Individual
Prefix:MS
First Name:MARIAH
Middle Name:T
Last Name:MOORE
Suffix:
Gender:F
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-635-9440
Mailing Address - Fax:859-448-2622
Practice Address - Street 1:300 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-2107
Practice Address - Country:US
Practice Address - Phone:859-635-9440
Practice Address - Fax:859-448-2622
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59821207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program