Provider Demographics
NPI:1518030154
Name:MOORE, MARIA ANNE (OD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:ANNE
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9225 S TRUMBULL AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1534
Mailing Address - Country:US
Mailing Address - Phone:312-307-7450
Mailing Address - Fax:
Practice Address - Street 1:9500 S WESTERN AVE
Practice Address - Street 2:STE G3A
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2856
Practice Address - Country:US
Practice Address - Phone:708-425-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009-773152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV06655Medicare UPIN
ILK21144Medicare ID - Type Unspecified