Healthcare Provider Details

I. General information

NPI: 1588291439
Provider Name (Legal Business Name): EMILY MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SMITH HAVEN MALL STE 101
LAKE GROVE NY
11755-1219
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-5437
  • Fax:
Mailing address:
  • Phone: 631-444-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number322245
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: