Provider Demographics
NPI:1043248735
Name:MOORE, KARIN RODRIGUEZ (OD)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:RODRIGUEZ
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 US HIGHWAY 411 S
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-8629
Mailing Address - Country:US
Mailing Address - Phone:865-681-8267
Mailing Address - Fax:
Practice Address - Street 1:2410 US HIGHWAY 411 S
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-8629
Practice Address - Country:US
Practice Address - Phone:865-681-8267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943794Medicaid
TNP00264124OtherRAILROAD MEDICARE PROV #
TN4121846OtherBCBS & TNCARE SELECT #
TN3943794Medicare PIN
TN3943794Medicaid