Provider Demographics
NPI:1245342898
Name:MOSES, BRODERICK DEVON (OD)
Entity type:Individual
Prefix:DR
First Name:BRODERICK
Middle Name:DEVON
Last Name:MOSES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:TARGET OPTICAL
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-5330
Mailing Address - Country:US
Mailing Address - Phone:504-454-3791
Mailing Address - Fax:504-456-3058
Practice Address - Street 1:4500 VETERANS MEMORIAL BLVD.
Practice Address - Street 2:TARGET OPTICAL
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-5330
Practice Address - Country:US
Practice Address - Phone:504-454-3791
Practice Address - Fax:504-456-3058
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6684TG152W00000X
LA1383-519T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1245342898OtherBLUE CROSS BLUE SHIELD OF TEXAS: INDIVIDUAL
TX1417146994OtherBLUE CROSS BLUE SHIELD OF TEXAS: GROUP
LA1627348Medicaid
TX82393QOtherBLUE CROSS BLUE SHIELD OF TEXAS
TXTXB128737Medicare PIN
LA1627348Medicaid