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

Table of content: DR. LEE RICHARD MOORE JR. O.D. (NPI 1306920913)

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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