Provider Demographics
NPI:1902240559
Name:MOORE, EVAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
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 1:1401 HARRODSBURG RD STE B75
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1724
Mailing Address - Country:US
Mailing Address - Phone:859-276-3883
Mailing Address - Fax:
Practice Address - Street 1:1401 HARRODSBURG RD STE B75
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1724
Practice Address - Country:US
Practice Address - Phone:859-276-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52794208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100324190Medicaid