Healthcare Provider Details

I. General information

NPI: 1154023851
Provider Name (Legal Business Name): CODY MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6675 HOLMES RD STE 550
KANSAS CITY MO
64131-1167
US

IV. Provider business mailing address

6314 W 54TH TER
MISSION KS
66202-1650
US

V. Phone/Fax

Practice location:
  • Phone: 816-363-7710
  • Fax:
Mailing address:
  • Phone: 573-275-0426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2026029564
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number05-53628
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: