Provider Demographics
NPI:1861463960
Name:MOORE, ANN GROOMER (OD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:GROOMER
Last Name:MOORE
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 1:8311 BANDFORD WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2756
Mailing Address - Country:US
Mailing Address - Phone:919-870-1880
Mailing Address - Fax:919-847-4509
Practice Address - Street 1:6566 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-7156
Practice Address - Country:US
Practice Address - Phone:919-783-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC410033568OtherRAILROAD MEDICARE
NC0483520001Medicare NSC
NCU02861Medicare UPIN
NC2467016AMedicare ID - Type Unspecified