Healthcare Provider Details

I. General information

NPI: 1710042882
Provider Name (Legal Business Name): ROBERT WILLIAM MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 FEATHERS DR
PLATTSBURGH NY
12901-6461
US

IV. Provider business mailing address

18 FEATHERS DRIVE
PLATTSBURGH NY
12901-1874
US

V. Phone/Fax

Practice location:
  • Phone: 518-324-2040
  • Fax: 518-324-2041
Mailing address:
  • Phone: 518-324-2040
  • Fax: 518-324-2041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number224246-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: