Provider Demographics
NPI:1770978645
Name:MOORE, NICHOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:MOORE
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 1:1462 MARION WALDO RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7422
Mailing Address - Country:US
Mailing Address - Phone:740-389-5418
Mailing Address - Fax:740-389-5410
Practice Address - Street 1:1462 MARION WALDO RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-389-5418
Practice Address - Fax:740-389-5410
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.135378207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty