Provider Demographics
NPI:1295878783
Name:POORE, P GEORGE (MD)
Entity type:Individual
Prefix:
First Name:P
Middle Name:GEORGE
Last Name:POORE
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:PO BOX 4777
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4777
Mailing Address - Country:US
Mailing Address - Phone:307-739-4662
Mailing Address - Fax:307-733-7679
Practice Address - Street 1:555 EAST BROADWAY STE 212
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-4777
Practice Address - Country:US
Practice Address - Phone:307-739-4662
Practice Address - Fax:307-733-7679
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5778A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D96279Medicare UPIN
9442Medicare ID - Type Unspecified