Basic Information
| Provider Information | |||||||||
| NPI: | 1366430241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033208499 | ||||||||
| FaxNumber: | 3033208620 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 E 9TH AVE | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033208499 | ||||||||
| FaxNumber: | 3033208620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 40114 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 201073340A | 05 | KS | MEDICAID | 00820041 | 05 | CO | MEDICAID |