1306920913 NPI number — DR. LEE RICHARD MOORE JR. O.D.

Table of content: JODIE D'ERMILIO (NPI 1235658105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306920913 NPI number — DR. LEE RICHARD MOORE JR. O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
LEE
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1306920913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PROSPECT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLES TOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25414-1137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 PROSPECT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLES TOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25414-1137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-725-1411
Provider Business Practice Location Address Fax Number:
304-725-1412
Provider Enumeration Date:
10/24/2006

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:  728OD , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2173688 . This is a "MAMSI" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 2716372 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001709879 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 2173688 . This is a "OPTIMUM CHOICE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 4534560 . This is a "AETNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 550624322 . This is a "TAX ID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 550624322001 . This is a "INFORMED" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 550624322AB . This is a "WELLS FARGO" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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