Provider Demographics
NPI:1780672279
Name:MOORE, DAVID NEIL (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:NEIL
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2235 RIDGEMOOR CT
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1391
Mailing Address - Country:US
Mailing Address - Phone:810-742-8618
Mailing Address - Fax:810-515-1219
Practice Address - Street 1:2235 RIDGEMOOR CT
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1391
Practice Address - Country:US
Practice Address - Phone:810-742-8618
Practice Address - Fax:810-515-1219
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002864152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B550570OtherBCBS
MI0983566Medicaid
MI0983566Medicaid
MI900B550570OtherBCBS
T32808Medicare UPIN