Provider Demographics
NPI:1053792069
Name:MOORE, WESLEY (DO)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-9706
Mailing Address - Country:US
Mailing Address - Phone:270-979-3241
Mailing Address - Fax:270-706-1920
Practice Address - Street 1:145 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-9706
Practice Address - Country:US
Practice Address - Phone:270-979-3241
Practice Address - Fax:270-706-1920
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine