Individual
MARK S MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1008 MINNEQUA AVE, PUEBLO, CO 81004-3733
(719) 557-4000
(970) 342-2093
Mailing address
PO BOX 7693, LOVELAND, CO 80537-0693
(970) 663-2742
(970) 342-2093
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
112240
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100180650B
OK CAID
—
01
—
100343220A
KS CAID
—
01
—
112240
MEDICAL LICENSE
MO
01
—
115634
MO BLUE
—
05
—
248699902
—
MO
01
—
451258
HLTLINK
—
05
—
83787844
—
CO
Enumeration date
08/18/2006
Last updated
11/05/2020
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