Provider Demographics
NPI:1144662248
Name:MOORE STUCK, KAITLIN B (DO)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:B
Last Name:MOORE STUCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:B
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:410 W 10TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210
Mailing Address - Country:US
Mailing Address - Phone:614-293-8487
Mailing Address - Fax:
Practice Address - Street 1:5151 REED RD STE 225C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2553
Practice Address - Country:US
Practice Address - Phone:614-884-0641
Practice Address - Fax:614-884-0776
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34012765207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program