Provider Demographics
NPI:1326213992
Name:MICHAEL D MOORE OD PS INC
Entity Type:Organization
Organization Name:MICHAEL D MOORE OD PS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-357-7899
Mailing Address - Street 1:2600 MARTIN WAY E
Mailing Address - Street 2:STE C
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4974
Mailing Address - Country:US
Mailing Address - Phone:360-357-7899
Mailing Address - Fax:360-357-6495
Practice Address - Street 1:2600 MARTIN WAY E
Practice Address - Street 2:STE C
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4974
Practice Address - Country:US
Practice Address - Phone:360-357-7899
Practice Address - Fax:360-357-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0149388OtherL & I
1770560708OtherNPI
WA2631703Medicaid
MM1253765OtherDEA
1770560708OtherNPI
WA2631703Medicaid