Provider Demographics
NPI:1518135672
Name:ROGER A MOORE OPTOMETRIST
Entity Type:Organization
Organization Name:ROGER A MOORE OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-426-2727
Mailing Address - Street 1:14 CHURCH HILL RD # C10
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1640
Mailing Address - Country:US
Mailing Address - Phone:203-426-2727
Mailing Address - Fax:203-426-5113
Practice Address - Street 1:14 CHURCH HILL RD # C10
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1640
Practice Address - Country:US
Practice Address - Phone:203-426-2727
Practice Address - Fax:203-426-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT950152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0123880001Medicare NSC