Provider Demographics
NPI:1871670620
Name:MOON EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:MOON EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-362-8191
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-0002
Mailing Address - Country:US
Mailing Address - Phone:501-362-8191
Mailing Address - Fax:501-362-3096
Practice Address - Street 1:509 N 2ND ST
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-2513
Practice Address - Country:US
Practice Address - Phone:501-362-8191
Practice Address - Fax:501-362-3096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49066Medicare PIN
AR0189770001Medicare NSC