Provider Demographics
NPI:1346338530
Name:MOORE, MARK DOUGLAS (O D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 N TYLER RD STE 124
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4916
Mailing Address - Country:US
Mailing Address - Phone:316-729-0083
Mailing Address - Fax:316-729-0052
Practice Address - Street 1:2020 N TYLER RD STE 124
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4916
Practice Address - Country:US
Practice Address - Phone:316-729-0083
Practice Address - Fax:316-729-0052
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1367152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS049695OtherBCBSKS
KS2531OtherPHS/PPK
KS018096OtherBCBSKS
KS2531OtherPHS/PPK
KS018096MOMedicare ID - Type Unspecified
KS018096OtherBCBSKS