Provider Demographics
NPI:1689803611
Name:MOORE, THOMAS WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WALTER
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 1:1 STEWART PLZ
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3041
Mailing Address - Country:US
Mailing Address - Phone:304-768-3332
Mailing Address - Fax:304-768-5115
Practice Address - Street 1:1 STEWART PLZ
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3041
Practice Address - Country:US
Practice Address - Phone:304-768-3332
Practice Address - Fax:304-768-5115
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1061-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018613Medicaid