Provider Demographics
NPI:1093768806
Name:MOORE, DIANA MCKENZIE (OD,PA)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MCKENZIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6925 WORTH AVE E
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-6797
Mailing Address - Country:US
Mailing Address - Phone:501-847-9898
Mailing Address - Fax:501-847-2599
Practice Address - Street 1:400 BRYANT AVE
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3813
Practice Address - Country:US
Practice Address - Phone:501-847-9898
Practice Address - Fax:501-847-9898
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist