Provider Demographics
NPI:1043328800
Name:MOORE, MARK D (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 PETERSON AVE S
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-5254
Mailing Address - Country:US
Mailing Address - Phone:912-389-1230
Mailing Address - Fax:912-389-1260
Practice Address - Street 1:504 PETERSON AVE S
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-5254
Practice Address - Country:US
Practice Address - Phone:912-389-1230
Practice Address - Fax:912-389-1260
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA457498953DMedicaid
GAGRP7442OtherMEDICARE PTAN
GA457498953DMedicaid