Provider Demographics
NPI:1477662138
Name:MOORE, STACIE L (OD)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:L
Last Name:MOORE
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:PO BOX 1137
Mailing Address - Street 2:223 W MAIN ST
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773
Mailing Address - Country:US
Mailing Address - Phone:662-494-2020
Mailing Address - Fax:662-492-0045
Practice Address - Street 1:223 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773
Practice Address - Country:US
Practice Address - Phone:662-494-2020
Practice Address - Fax:662-492-0045
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880170Medicaid
MS410000228Medicare ID - Type Unspecified
MS00880170Medicaid