Provider Demographics
NPI:1275721409
Name:MOOMEY, ELTON JACK (OD)
Entity Type:Individual
Prefix:DR
First Name:ELTON
Middle Name:JACK
Last Name:MOOMEY
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 1:127 S BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9111
Mailing Address - Country:US
Mailing Address - Phone:706-869-1800
Mailing Address - Fax:706-855-8159
Practice Address - Street 1:127 S BELAIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9111
Practice Address - Country:US
Practice Address - Phone:706-869-1800
Practice Address - Fax:706-855-8159
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT87001Medicare UPIN