Healthcare Provider Details

I. General information

NPI: 1902837198
Provider Name (Legal Business Name): BRUCE B MOOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PINE GROVE AVE
KINGSTON NY
12401-5407
US

IV. Provider business mailing address

PO BOX 2270
KINGSTON NY
12402-2270
US

V. Phone/Fax

Practice location:
  • Phone: 845-943-5841
  • Fax: 845-338-5616
Mailing address:
  • Phone: 845-943-5841
  • Fax: 845-338-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number123654
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: