Provider Demographics
NPI:1659343317
Name:MOOREHEAD, MICHAEL H
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:MOOREHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 EATON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-1407
Mailing Address - Country:US
Mailing Address - Phone:513-894-1800
Mailing Address - Fax:513-894-6315
Practice Address - Street 1:1360 EATON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1407
Practice Address - Country:US
Practice Address - Phone:513-894-1800
Practice Address - Fax:513-894-6315
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0720474Medicaid
OH410008895OtherMEDICARE RAILROAD PTAN
OH0377810001Medicare NSC
OH410008895OtherMEDICARE RAILROAD PTAN
OH0620601Medicare PIN