Provider Demographics
NPI:1639520943
Name:MOORE, LAUREN THERESA (OD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:THERESA
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FARM COLONY DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-5206
Mailing Address - Country:US
Mailing Address - Phone:814-726-2303
Mailing Address - Fax:
Practice Address - Street 1:2 FARM COLONY DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-5203
Practice Address - Country:US
Practice Address - Phone:716-484-6700
Practice Address - Fax:716-487-0166
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103132650Medicaid
NY04524503Medicaid