Provider Demographics
NPI:1184468126
Name:MORAN, BENJAMIN WALKER
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WALKER
Last Name:MORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8760 PINNACLE PARK BLVD APT 1132
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3113
Mailing Address - Country:US
Mailing Address - Phone:720-917-4026
Mailing Address - Fax:
Practice Address - Street 1:4413 TOWN CENTER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8568
Practice Address - Country:US
Practice Address - Phone:904-998-9822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist