Basic Information
| Provider Information | |||||||||
| NPI: | 1588837181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN STE 101 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | M8851 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8P8741 | 01 | TX | TX BCBS | OTHER | 197148301 | 05 | TX | MEDICAID | P00808584 | 01 | TX | RR MEDICARE | OTHER |