Provider Demographics
NPI:1164736583
Name:SMALL, HEATHER MOON (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MOON
Last Name:SMALL
Suffix:
Gender:F
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 178
Mailing Address - Street 2:
Mailing Address - City:CAPSHAW
Mailing Address - State:AL
Mailing Address - Zip Code:35742-0178
Mailing Address - Country:US
Mailing Address - Phone:256-230-9637
Mailing Address - Fax:256-230-0143
Practice Address - Street 1:27453 CAPSHAW RD STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-7565
Practice Address - Country:US
Practice Address - Phone:256-230-9637
Practice Address - Fax:256-230-0143
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL631274146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL126155Medicaid
AL126155Medicaid