Provider Demographics
NPI:1821466681
Name:MOYA, MARCELO (OD)
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:
Last Name:MOYA
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 1:3051 GARDEN AVE BLDG 1279
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7537
Mailing Address - Country:US
Mailing Address - Phone:505-249-9655
Mailing Address - Fax:210-539-2086
Practice Address - Street 1:786 D STREET
Practice Address - Street 2:
Practice Address - City:JOINT BASE ELMENDORF-RICHARDSON (JBER)
Practice Address - State:AK
Practice Address - Zip Code:99505
Practice Address - Country:US
Practice Address - Phone:505-249-9655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist