Healthcare Provider Details

I. General information

NPI: 1104280478
Provider Name (Legal Business Name): STEPHEN MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E 19TH AVE STE 520
DENVER CO
80218-1243
US

IV. Provider business mailing address

1721 E 19TH AVE STE 520
DENVER CO
80218-1243
US

V. Phone/Fax

Practice location:
  • Phone: 303-839-6741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number65302
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29924
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number65302
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: