Provider Demographics
NPI:1700879756
Name:MORAN, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:MORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 GOLF COURSE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-3433
Mailing Address - Fax:218-326-3435
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20816207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN180001387OtherINDIVIDUAL MEDICARE NUMBER GRAND RAPIDS
MN180001388OtherINDIVIDUAL MEDICARE NUMBER HIBBING
MNC02738OtherMEDICARE PROVIDER NUMBER HIBBING
MNC08247OtherMEDICARE GRAND RAPIDS PROVIDER NUMBER
MN410991065OtherEIN
MNC02738OtherMEDICARE PROVIDER NUMBER HIBBING