Provider Demographics
NPI:1356442701
Name:MORIARTY, RICHARD J (LO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:MORIARTY
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2538
Mailing Address - Country:US
Mailing Address - Phone:203-734-3309
Mailing Address - Fax:203-735-4431
Practice Address - Street 1:552 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2538
Practice Address - Country:US
Practice Address - Phone:203-734-3309
Practice Address - Fax:203-735-4431
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTL.O. 610156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician