Provider Demographics
NPI:1669470589
Name:MORAN, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 14TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6827
Mailing Address - Country:US
Mailing Address - Phone:605-886-7722
Mailing Address - Fax:605-886-7723
Practice Address - Street 1:705 14TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6827
Practice Address - Country:US
Practice Address - Phone:605-886-7722
Practice Address - Fax:605-886-7723
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4579207W00000X, 156FC0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6301483Medicaid
21438OtherSIOUX VALLEY HEALTH
SD4305930001Medicare NSC
G97249Medicare UPIN
8352Medicare ID - Type Unspecified