Provider Demographics
NPI:1215385364
Name:QUESADA MOORE, STEPHANIE (OD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:QUESADA MOORE
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 1:802 BEACHCOMBER DR
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3420
Mailing Address - Country:US
Mailing Address - Phone:850-866-8472
Mailing Address - Fax:
Practice Address - Street 1:2638 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4387
Practice Address - Country:US
Practice Address - Phone:850-215-2020
Practice Address - Fax:850-215-2031
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5212152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation