Provider Demographics
NPI:1093726523
Name:MOOSE, RICHARD E (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:MOOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4400 VESTAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13902-4400
Mailing Address - Country:US
Mailing Address - Phone:607-777-2221
Mailing Address - Fax:607-777-2881
Practice Address - Street 1:DECKER STUDENT HEALTH SERVICES CENTER
Practice Address - Street 2:4400 VESTAL PARKWAY EAST
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13902
Practice Address - Country:US
Practice Address - Phone:607-777-2221
Practice Address - Fax:607-777-2881
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203760-1207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF89792Medicare UPIN
NYRA9086Medicare PIN