Provider Demographics
NPI:1871547612
Name:MOEN, ROBERT MARCUS (ODO1/)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARCUS
Last Name:MOEN
Suffix:
Gender:M
Credentials:ODO1/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5154 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9281
Mailing Address - Country:US
Mailing Address - Phone:262-677-3979
Mailing Address - Fax:
Practice Address - Street 1:1710 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-4938
Practice Address - Country:US
Practice Address - Phone:262-334-7077
Practice Address - Fax:262-338-3505
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38577100Medicaid
WI1823Medicare UPIN