Provider Demographics
NPI:1033420575
Name:MOORE, BRIAN (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
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 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7015
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-3068
Practice Address - Street 1:200 E MECHANIC ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-2007
Practice Address - Country:US
Practice Address - Phone:217-532-3036
Practice Address - Fax:217-532-6623
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist