Provider Demographics
NPI:1306163878
Name:MOORE, RODGER ALLEN (HIS)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:ALLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6717 S YALE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3311
Mailing Address - Country:US
Mailing Address - Phone:918-834-3933
Mailing Address - Fax:918-834-7490
Practice Address - Street 1:443 STONE WOOD DR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1026
Practice Address - Country:US
Practice Address - Phone:918-451-7020
Practice Address - Fax:918-451-7021
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK896237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist