Provider Demographics
NPI:1083672190
Name:MOORE, TIMOTHY GLEN (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GLEN
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:PO BOX 15349
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-5349
Mailing Address - Country:US
Mailing Address - Phone:850-383-3322
Mailing Address - Fax:
Practice Address - Street 1:1491 GOVERNORS SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3049
Practice Address - Country:US
Practice Address - Phone:850-383-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
19704ZMedicare ID - Type Unspecified
T85257Medicare UPIN