Provider Demographics
NPI:1730226515
Name:MOORE, TRUDY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:TRUDY
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GERTRUDE
Other - Middle Name:ANN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:890 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-7487
Mailing Address - Country:US
Mailing Address - Phone:606-666-9112
Mailing Address - Fax:
Practice Address - Street 1:265 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-7370
Practice Address - Country:US
Practice Address - Phone:606-464-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY24633OtherMEDICAL LICENSE
KY24633OtherMEDICAL LICENSE
BM0460408OtherDEA NUMBER