Provider Demographics
NPI:1275505489
Name:MOORE, THOMAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
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 1:7 WEST 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2301
Mailing Address - Country:US
Mailing Address - Phone:859-431-7966
Mailing Address - Fax:
Practice Address - Street 1:7 WEST 7TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-2301
Practice Address - Country:US
Practice Address - Phone:859-431-7966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY996DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000033554OtherANTHEM
KY77009967Medicaid
KY9179401Medicare PIN
000000033554OtherANTHEM
T92635Medicare UPIN
0129140001Medicare NSC