Provider Demographics
NPI:1023365020
Name:MORAN, JOHN EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:MORAN
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 1:2974 SYRACUSE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3304
Mailing Address - Country:US
Mailing Address - Phone:313-330-1151
Mailing Address - Fax:
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3574
Practice Address - Country:US
Practice Address - Phone:313-827-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist