Provider Demographics
NPI:1114078607
Name:MORAN, ANTONIO (OD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MORAN
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 127
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-0127
Mailing Address - Country:US
Mailing Address - Phone:510-928-6187
Mailing Address - Fax:
Practice Address - Street 1:1212 HILLTOP MALL RD
Practice Address - Street 2:STE D-112
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1910
Practice Address - Country:US
Practice Address - Phone:510-223-9770
Practice Address - Fax:510-223-9774
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0113120Medicare ID - Type Unspecified
CAU98132Medicare UPIN