Basic Information
| Provider Information | |||||||||
| NPI: | 1225185044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707815111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 484 GOLDEN AUTUMN WAY STE 201 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421036914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707802494 | ||||||||
| FaxNumber: | 2707800465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 42630 | KY | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 7100080340 | 05 | KY | MEDICAID |