Provider Demographics
NPI:1700817210
Name:MOORE, CHAD EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:EDWIN
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1531 WEST 32ND STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1651
Mailing Address - Country:US
Mailing Address - Phone:417-781-3630
Mailing Address - Fax:417-781-9814
Practice Address - Street 1:1531 WEST 32ND STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1651
Practice Address - Country:US
Practice Address - Phone:417-781-3630
Practice Address - Fax:417-781-9814
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200383240AMedicaid
MO212451OtherBC/BS
MO311200307Medicaid
MOP00331964Medicare PIN
KS200383240AMedicaid
MO259801564Medicare PIN