Provider Demographics
NPI:1821089970
Name:MORELAND, AMBER R (OD)
Entity Type:Individual
Prefix:DR
First Name:AMBER
Middle Name:R
Last Name:MORELAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 ANNA NURSERY LN
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920-3671
Mailing Address - Country:US
Mailing Address - Phone:618-833-4690
Mailing Address - Fax:618-833-3142
Practice Address - Street 1:125 LEIGH AVE
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-2203
Practice Address - Country:US
Practice Address - Phone:618-833-9208
Practice Address - Fax:618-833-3142
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK37163Medicare ID - Type Unspecified
ILV07042Medicare UPIN