Provider Demographics
NPI:1588694194
Name:MOEN, BRUCE ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:MOEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 31ST AVE SW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-2007
Mailing Address - Country:US
Mailing Address - Phone:701-837-0022
Mailing Address - Fax:701-839-2005
Practice Address - Street 1:1100 31ST AVE SW
Practice Address - Street 2:SUITE 2
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-2007
Practice Address - Country:US
Practice Address - Phone:701-837-0022
Practice Address - Fax:701-839-2005
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60328Medicaid
ND60328Medicaid
ND22882Medicare PIN