Basic Information
| Provider Information | |||||||||
| NPI: | 1104354505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | KALEB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 545 VITALITY DR STE 100A | ||||||||
| Address2: | |||||||||
| City: | FORTVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460401373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176219220 | ||||||||
| FaxNumber: | 3176219222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2017 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | KY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 01086091A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.