Provider Demographics
NPI:1194795971
Name:MOORE, MICHELLE ELIZABETH (O D)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2214
Mailing Address - Country:US
Mailing Address - Phone:860-793-1330
Mailing Address - Fax:
Practice Address - Street 1:683 BROAD ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6662
Practice Address - Country:US
Practice Address - Phone:860-583-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT2482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT906456OtherBLOCK VISION
CT0V5039OtherHNET
CT599721OtherCT. CARE
CTC01127Medicare PIN
CT0V5039OtherHNET
CTU71494Medicare UPIN