Provider Demographics
NPI:1891874731
Name:MOORE, JAN SOLOMON (OD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:SOLOMON
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:SOLOMON
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:14434 HAMLIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1461
Mailing Address - Country:US
Mailing Address - Phone:818-785-4040
Mailing Address - Fax:818-785-4608
Practice Address - Street 1:14434 HAMLIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1461
Practice Address - Country:US
Practice Address - Phone:818-785-4040
Practice Address - Fax:818-785-4608
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8910TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089100Medicaid
CASD0089100Medicaid
CAWOP8910AMedicare PIN