Provider Demographics
NPI:1124367750
Name:MOORE, STEPHEN HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:HENRY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 VERNON CIR
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3053
Mailing Address - Country:US
Mailing Address - Phone:612-760-1264
Mailing Address - Fax:
Practice Address - Street 1:2300 VERNON CIR
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55305-3053
Practice Address - Country:US
Practice Address - Phone:612-760-1264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120886207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine