Provider Demographics
NPI:1477618551
Name:MOORE, HEIDI JILL (MD)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:JILL
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:600 BLAIR PARK RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7586
Mailing Address - Country:US
Mailing Address - Phone:802-872-4343
Mailing Address - Fax:802-872-0282
Practice Address - Street 1:159 MARGARET ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1874
Practice Address - Country:US
Practice Address - Phone:518-562-0151
Practice Address - Fax:518-562-2718
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2014-02-05
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Provider Licenses
StateLicense IDTaxonomies
NY223912-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743295Medicaid