Provider Demographics
NPI:1215058243
Name:MOBERLY EYE CENTER INC
Entity type:Organization
Organization Name:MOBERLY EYE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:660-263-4261
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0696
Mailing Address - Country:US
Mailing Address - Phone:660-263-4261
Mailing Address - Fax:660-263-0958
Practice Address - Street 1:1633 S MORLEY ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1938
Practice Address - Country:US
Practice Address - Phone:660-263-4261
Practice Address - Fax:660-263-0958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03120152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318272812Medicaid
MOU62421Medicare UPIN
MO318272812Medicaid
MO1284410001Medicare NSC