Provider Demographics
NPI:1629062807
Name:MOORE, BRADLEY T (DO)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:T
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 KY RTE 306
Mailing Address - Street 2:
Mailing Address - City:BYPRO
Mailing Address - State:KY
Mailing Address - Zip Code:41612
Mailing Address - Country:US
Mailing Address - Phone:606-452-1700
Mailing Address - Fax:606-452-1703
Practice Address - Street 1:62 KY RTE 306
Practice Address - Street 2:
Practice Address - City:BYPRO
Practice Address - State:KY
Practice Address - Zip Code:41612
Practice Address - Country:US
Practice Address - Phone:606-452-1700
Practice Address - Fax:606-452-1703
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64106719Medicaid
KY0258136Medicare ID - Type Unspecified
I32354Medicare UPIN
KY64106719Medicaid