Provider Demographics
NPI:1083643589
Name:MOORE, STEPHEN T (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1101 NEAL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0901
Mailing Address - Country:US
Mailing Address - Phone:931-526-1581
Mailing Address - Fax:
Practice Address - Street 1:1101 NEAL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0917
Practice Address - Country:US
Practice Address - Phone:931-526-1581
Practice Address - Fax:931-526-5973
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO00000013052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3305996Medicaid
TN621833951OtherTAX ID/PROVIDER NUMBER
TN3158681OtherBCBS PROVIDER NUMBER
TNE71199Medicare UPIN
TN3305996Medicaid