Provider Demographics
NPI:1669476214
Name:MOORE, ROGER (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MOORE
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 1:14 CHURCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1640
Mailing Address - Country:US
Mailing Address - Phone:203-426-2727
Mailing Address - Fax:203-426-5113
Practice Address - Street 1:14 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1640
Practice Address - Country:US
Practice Address - Phone:203-426-2727
Practice Address - Fax:203-426-5113
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT950152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0123880001OtherMEDICARE - DME
090000950CT01OtherANTHEM BC
CTP620522OtherOXFORD
4321240OtherAETNA
CT004067195Medicaid
CT0123880001OtherMEDICARE - DME
T22697Medicare UPIN