Provider Demographics
NPI:1871701300
Name:MOORE BISHOP, KATHLEEN E (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:MOORE BISHOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8180 E OCOTILLO DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-9665
Mailing Address - Country:US
Mailing Address - Phone:520-749-3771
Mailing Address - Fax:
Practice Address - Street 1:1800 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5303
Practice Address - Country:US
Practice Address - Phone:520-381-6105
Practice Address - Fax:520-381-6060
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25817207Q00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
220806OtherINDIVIDUAL AHCCCS ID#
AZZ131330Medicare PIN