Provider Demographics
NPI:1003868670
Name:MOORE, CHARLIE JIM (OD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:JIM
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 1:2481 I 40 W
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109
Mailing Address - Country:US
Mailing Address - Phone:806-358-2205
Mailing Address - Fax:806-463-2907
Practice Address - Street 1:2481 I 40 W
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109
Practice Address - Country:US
Practice Address - Phone:806-358-2205
Practice Address - Fax:806-463-2907
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2740TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1331696-07Medicaid
TX00397EMedicare PIN