Provider Demographics
NPI:1346724556
Name:MOONEY, KAITLIN MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MICHELLE
Last Name:MOONEY
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 1:3059 48TH ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1517
Mailing Address - Country:US
Mailing Address - Phone:845-863-9091
Mailing Address - Fax:
Practice Address - Street 1:10306 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2330
Practice Address - Country:US
Practice Address - Phone:718-424-1333
Practice Address - Fax:718-424-1330
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist