Provider Demographics
NPI:1275521486
Name:MOORE, KATHLEEN BRADY (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:BRADY
Last Name:MOORE
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 1:13880 BRADDOCK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2459
Mailing Address - Country:US
Mailing Address - Phone:703-830-2020
Mailing Address - Fax:703-830-4458
Practice Address - Street 1:13880 BRADDOCK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2459
Practice Address - Country:US
Practice Address - Phone:703-830-2020
Practice Address - Fax:703-830-4458
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA595931Medicare ID - Type Unspecified