Provider Demographics
NPI:1730289935
Name:MOORE, MARK EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
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 1:3333 S CRATER RD STE 2D
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9276
Mailing Address - Country:US
Mailing Address - Phone:804-732-3937
Mailing Address - Fax:804-733-6005
Practice Address - Street 1:3333 S CRATER RD STE 2D
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9276
Practice Address - Country:US
Practice Address - Phone:804-732-3937
Practice Address - Fax:804-733-6005
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080634OtherBLUE CROSS
VA009235221Medicaid
VA080634OtherBLUE CROSS
VA009235221Medicaid