Provider Demographics
NPI:1215027495
Name:MOOREHEAD, ANDREA M (OD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:MOOREHEAD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 EATON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-1407
Mailing Address - Country:US
Mailing Address - Phone:513-894-1800
Mailing Address - Fax:513-894-6315
Practice Address - Street 1:1360 EATON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1407
Practice Address - Country:US
Practice Address - Phone:513-894-1800
Practice Address - Fax:513-894-6315
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2930707Medicaid
OH2930707Medicaid