Provider Demographics
NPI:1104892983
Name:MOORE, ROBERT A (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:1400 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2201
Practice Address - Country:US
Practice Address - Phone:316-320-2200
Practice Address - Fax:316-321-0430
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100219320BMedicaid
KS410029647OtherRAILROAD MEDICARE
KS014706Medicare PIN
KS410029647OtherRAILROAD MEDICARE