Provider Demographics
NPI:1821023839
Name:MOORE, GREGORY S (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2292
Practice Address - Country:US
Practice Address - Phone:304-472-1235
Practice Address - Fax:304-472-1234
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL843-IODF152W00000X
MDDA2907152W00000X
WV843OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist