Provider Demographics
NPI:1629555131
Name:MOORE, CANDICE M (OD)
Entity Type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:860 PEACHTREE ST NE STE F
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1288
Practice Address - Country:US
Practice Address - Phone:404-853-5008
Practice Address - Fax:404-853-5009
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOPC5582152W00000X, 152WP0200X, 152WS0006X, 152WV0400X, 152WC0802X
GAOPT003127152W00000X
FLOPC5822152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision