Healthcare Provider Details

I. General information

NPI: 1144842378
Provider Name (Legal Business Name): ANDREW E MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 PERRY LN
MERRIAM KS
66203-4827
US

IV. Provider business mailing address

5113 PERRY LN
MERRIAM KS
66203-4827
US

V. Phone/Fax

Practice location:
  • Phone: 505-360-1424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number85340
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-53107
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: