Provider Demographics
NPI:1629458930
Name:MOEN, GARRETT (OD)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:
Last Name:MOEN
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:ICO BOX 94
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4201
Mailing Address - Country:US
Mailing Address - Phone:701-720-0009
Mailing Address - Fax:
Practice Address - Street 1:658 GENOA WAY STE B
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-3891
Practice Address - Country:US
Practice Address - Phone:303-337-2020
Practice Address - Fax:303-337-2053
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003156152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1467957746Medicaid