Provider Demographics
NPI:1831191279
Name:MOORE, BRUCE (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MOORE
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 1:930 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1220
Mailing Address - Country:US
Mailing Address - Phone:617-262-2020
Mailing Address - Fax:617-236-6323
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1220
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:617-236-6323
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2514152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0313815Medicaid
MA0313815Medicaid
MAW17028Medicare ID - Type Unspecified