Provider Demographics
NPI:1780612499
Name:MOORE-ELCYZYN, AMANDA LEANNE (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEANNE
Last Name:MOORE-ELCYZYN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEANNE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1926 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3957
Mailing Address - Country:US
Mailing Address - Phone:208-336-2020
Mailing Address - Fax:208-384-5677
Practice Address - Street 1:113 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3317
Practice Address - Country:US
Practice Address - Phone:501-778-2363
Practice Address - Fax:501-778-5329
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2566152W00000X
IDODP-100499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49956OtherMEDICARE #
AR161893722Medicaid
AR0250800001Medicare NSC
ARV09938Medicare UPIN