Provider Demographics
NPI:1447275557
Name:MOORE, JEFFREY (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:5142 SW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-7119
Mailing Address - Country:US
Mailing Address - Phone:239-549-2506
Mailing Address - Fax:
Practice Address - Street 1:4455 CLEVELAND AVE STE A
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9057
Practice Address - Country:US
Practice Address - Phone:239-939-5393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78430300Medicaid
FLT84144Medicare UPIN
FL19703Medicare ID - Type Unspecified