Provider Demographics
NPI:1497826655
Name:MOORE, EVELYN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:MARIE
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 1:2032 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1240
Mailing Address - Country:US
Mailing Address - Phone:217-954-1085
Mailing Address - Fax:217-607-5457
Practice Address - Street 1:2032 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1240
Practice Address - Country:US
Practice Address - Phone:217-954-1085
Practice Address - Fax:217-607-5457
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.006881152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001084006OtherBLUE CROSS BLUE SHIELD
IL0001084006OtherBLUE CROSS BLUE SHIELD
ILT37556Medicare UPIN
IL659110Medicare PIN