Provider Demographics
NPI:1982887493
Name:MOORE, STACEY DENISE (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DENISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20211 CYPRESSWOOD ESTATES RUN APT 4718
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77373-3295
Mailing Address - Country:US
Mailing Address - Phone:832-496-4855
Mailing Address - Fax:
Practice Address - Street 1:1550 FIRST COLONY BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-4000
Practice Address - Country:US
Practice Address - Phone:281-275-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8193208600000X
IL0361399322086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196912302Medicaid
TX8CA598OtherBCBS
TX196912302Medicaid
Z99061Medicare UPIN