Provider Demographics
NPI:1487695409
Name:MOORE, RICHARD ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ROBERT
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BOYLE RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-4030
Mailing Address - Country:US
Mailing Address - Phone:631-736-4064
Mailing Address - Fax:631-736-1332
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL MEDICAL CENTER
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-4088
Practice Address - Fax:631-376-4539
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1590991207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00860540Medicaid
A61549Medicare UPIN
NY25D241Medicare ID - Type Unspecified