Provider Demographics
NPI:1760425433
Name:POORE, SAMUEL O (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:O
Last Name:POORE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-7502
Practice Address - Fax:608-265-9695
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49936208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery