Provider Demographics
NPI:1902955149
Name:MOORE, STEPHANIE POLK (MD)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:POLK
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:159 MARGARET ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1874
Mailing Address - Country:US
Mailing Address - Phone:518-324-2040
Mailing Address - Fax:518-324-2041
Practice Address - Street 1:159 MARGARET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1874
Practice Address - Country:US
Practice Address - Phone:518-324-2040
Practice Address - Fax:518-324-2041
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY224178-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743295Medicaid