Provider Demographics
NPI:1710042882
Name:MOORE, ROBERT WILLIAM (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
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 1:18 FEATHERS DRIVE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1874
Mailing Address - Country:US
Mailing Address - Phone:518-324-2040
Mailing Address - Fax:518-324-2041
Practice Address - Street 1:18 FEATHERS DR
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6461
Practice Address - Country:US
Practice Address - Phone:518-324-2040
Practice Address - Fax:518-324-2041
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224246-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743295Medicaid