Provider Demographics
NPI:1619928363
Name:MOORE, ANDREW CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CHARLES
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DREIER BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-5037
Mailing Address - Country:US
Mailing Address - Phone:812-423-8302
Mailing Address - Fax:
Practice Address - Street 1:2311 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-5118
Practice Address - Country:US
Practice Address - Phone:812-425-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001508A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN197510CMedicare ID - Type Unspecified
INU21113Medicare UPIN