Provider Demographics
NPI:1851778674
Name:MOORE, FLETCHER BRADY (MD)
Entity type:Individual
Prefix:DR
First Name:FLETCHER
Middle Name:BRADY
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:834 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2443
Practice Address - Country:US
Practice Address - Phone:360-385-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1575572085R0202X
WV279312085R0202X
MDD887882085R0202X
WAMD616818392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC086220957Medicaid
WA2334210Medicaid
MD184182300Medicaid