Provider Demographics
NPI:1124073770
Name:MOORE, JEFFREY EDWARD (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:EDWARD
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 1:213 W THIRD AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365
Mailing Address - Country:US
Mailing Address - Phone:814-723-4470
Mailing Address - Fax:814-723-5413
Practice Address - Street 1:213 W THIRD AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365
Practice Address - Country:US
Practice Address - Phone:814-723-4470
Practice Address - Fax:814-723-5413
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0EG000559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAM01647445OtherPA BLUE SHIELD