Healthcare Provider Details

I. General information

NPI: 1760471304
Provider Name (Legal Business Name): KEITH R MOORE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 DYLAN LOREN CIR SUITE 102
ORLANDO FL
32825-4437
US

IV. Provider business mailing address

9500 S DADELAND BLVD STE 200
MIAMI FL
33156-2866
US

V. Phone/Fax

Practice location:
  • Phone: 407-277-8665
  • Fax: 407-277-1267
Mailing address:
  • Phone: 786-530-3820
  • Fax: 305-675-3378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS6231
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: