1245342898 NPI number — DR. BRODERICK DEVON MOSES O.D.

Table of content: MRS. KIRSTEN HAMILTON R.D.N., L.D.N. (NPI 1336565233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245342898 NPI number — DR. BRODERICK DEVON MOSES O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSES
Provider First Name:
BRODERICK
Provider Middle Name:
DEVON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245342898
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 VETERANS MEMORIAL BLVD
Provider Second Line Business Mailing Address:
TARGET OPTICAL
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70006-5330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-454-3791
Provider Business Mailing Address Fax Number:
504-456-3058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 VETERANS MEMORIAL BLVD.
Provider Second Line Business Practice Location Address:
TARGET OPTICAL
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70006-5330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-454-3791
Provider Business Practice Location Address Fax Number:
504-456-3058
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  6684TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1383-519T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1245342898 . This is a "BLUE CROSS BLUE SHIELD OF TEXAS: INDIVIDUAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1417146994 . This is a "BLUE CROSS BLUE SHIELD OF TEXAS: GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1627348 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82393Q . This is a "BLUE CROSS BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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