Provider Demographics
NPI:1093818023
Name:MOORE, MICHAEL VAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VAN
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 1:2132 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-2603
Mailing Address - Country:US
Mailing Address - Phone:806-747-1635
Mailing Address - Fax:806-747-5499
Practice Address - Street 1:2132 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-2603
Practice Address - Country:US
Practice Address - Phone:806-747-1635
Practice Address - Fax:806-747-5499
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2209T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0930109-02Medicaid
TX410020884OtherRAILROAD MEDICARE
TX0930109-01Medicaid
TX0672830002Medicare NSC
TX00D93CMedicare PIN
TX0930109-01Medicaid
TX0672830001Medicare NSC
TX0930109-02Medicaid