Provider Demographics
NPI:1023096054
Name:MOORE, KEVIN DALE (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DALE
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:34 MONUMENT DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8508
Mailing Address - Country:US
Mailing Address - Phone:571-409-0161
Mailing Address - Fax:540-288-3327
Practice Address - Street 1:450 GARRISONVILLE RD
Practice Address - Street 2:109
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554
Practice Address - Country:US
Practice Address - Phone:703-522-2727
Practice Address - Fax:540-288-3327
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282002084F0202X, 2084P0800X, 2084P0802X
NC2014-010192084P0800X
VA01012550192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry