Provider Demographics
NPI:1851367817
Name:MORAN, JASON PATRICK (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:PATRICK
Last Name:MORAN
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 1:1210A MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-3506
Mailing Address - Country:US
Mailing Address - Phone:931-431-7876
Mailing Address - Fax:
Practice Address - Street 1:5989 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FT. CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-956-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD 2582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist