Provider Demographics
NPI:1962578864
Name:MOYER, KIM E (OD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:E
Last Name:MOYER
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 1:215 W KELLNER BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-2665
Mailing Address - Country:US
Mailing Address - Phone:574-946-0777
Mailing Address - Fax:
Practice Address - Street 1:215 W KELLNER BLVD STE 12
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2665
Practice Address - Country:US
Practice Address - Phone:574-946-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001961B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300025829Medicaid
IN100210730AMedicaid
IN100210730CMedicaid
IN391050Medicare ID - Type UnspecifiedMEDICARE B
IN0306810002Medicare NSC