Provider Demographics
NPI:1225195589
Name:MOORE, HOWARD (OD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:
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 1:1133 FOX MEADOWS BLVD
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-6923
Mailing Address - Country:US
Mailing Address - Phone:865-453-8444
Mailing Address - Fax:
Practice Address - Street 1:1133 FOX MEADOWS BLVD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6923
Practice Address - Country:US
Practice Address - Phone:865-453-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3713646Medicaid
TN394128Medicare ID - Type Unspecified
TN3713646Medicaid