Provider Demographics
NPI:1942296017
Name:MOORE, ALLAN WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1180 WARM SPRINGS HWY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:GA
Practice Address - Zip Code:31816-1166
Practice Address - Country:US
Practice Address - Phone:706-846-2131
Practice Address - Fax:706-846-3517
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA888T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA162199146AMedicaid
GA4811300001OtherPALMETTO GBA NSC
GAGRP5120Medicare Oscar/Certification
GA41ZCFJCMedicare PIN