Provider Demographics
NPI:1992885412
Name:KORTE-MOORE, KIM (OD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:KORTE-MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 QUAIL CT
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-8047
Mailing Address - Country:US
Mailing Address - Phone:330-726-8405
Mailing Address - Fax:
Practice Address - Street 1:6000 MAHONING AVE
Practice Address - Street 2:STE. 394
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2240
Practice Address - Country:US
Practice Address - Phone:330-797-3120
Practice Address - Fax:330-797-3126
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4027T1760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT80596Medicare UPIN
OHM00620702Medicare PIN