Provider Demographics
NPI:1871554527
Name:MOORE, BRIAN HAROLD (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:HAROLD
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2212
Mailing Address - Country:US
Mailing Address - Phone:812-330-0303
Mailing Address - Fax:812-330-0404
Practice Address - Street 1:813 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2212
Practice Address - Country:US
Practice Address - Phone:812-330-0303
Practice Address - Fax:812-330-0404
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060196A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200514350Medicaid
IN200514350Medicaid