Provider Demographics
NPI:1699932012
Name:MOORE, SALLY WONG (OD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:WONG
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 1:8223 PINE LOG CT
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-6152
Mailing Address - Country:US
Mailing Address - Phone:251-753-2978
Mailing Address - Fax:
Practice Address - Street 1:10040 COUNTY ROAD 48
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36533
Practice Address - Country:US
Practice Address - Phone:251-990-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSA38TA597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist