Provider Demographics
NPI:1306920913
Name:MOORE, LEE RICHARD JR (OD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:RICHARD
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-1137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1137
Practice Address - Country:US
Practice Address - Phone:304-725-1411
Practice Address - Fax:304-725-1412
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV728OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2173688OtherMAMSI
WV2716372OtherUNITED HEALTH CARE
WV001709879OtherBLUE CROSS BLUE SHIELD
WV2173688OtherOPTIMUM CHOICE
WV4534560OtherAETNA
WV550624322OtherTAX ID
WV550624322001OtherINFORMED
WV550624322ABOtherWELLS FARGO
WV4534560OtherAETNA