Provider Demographics
NPI:1467491274
Name:MOORE, SANDRA M (OD)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:M
Last Name: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 1:2139 COTTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1122
Mailing Address - Country:US
Mailing Address - Phone:215-745-1444
Mailing Address - Fax:215-745-1448
Practice Address - Street 1:2139 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1122
Practice Address - Country:US
Practice Address - Phone:215-745-1444
Practice Address - Fax:215-745-1448
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001074152W00000X
PWOEG001074152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2193348000OtherINDEPENDENCE BLUE CROSS
PA2193348000OtherKEYSTONE HEALTH PLAN EAST
PA2193348000OtherKEYSTONE HEALTH PLAN EAST
PA2193348000OtherINDEPENDENCE BLUE CROSS