Provider Demographics
NPI:1043379449
Name:MOORE, DEBRA ANN (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 WEST VINCENNES ST
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441
Mailing Address - Country:US
Mailing Address - Phone:812-847-9998
Mailing Address - Fax:630-463-5277
Practice Address - Street 1:269 WEST VINCENNES ST
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441
Practice Address - Country:US
Practice Address - Phone:812-847-9998
Practice Address - Fax:630-463-5277
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200295430AMedicaid
IN200295430AMedicaid