Provider Demographics
NPI:1679574396
Name:MOORE, DOUGLAS LORAN (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LORAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1902 W 19TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1287
Mailing Address - Country:US
Mailing Address - Phone:417-926-3937
Mailing Address - Fax:417-926-3952
Practice Address - Street 1:1902 W 19TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1287
Practice Address - Country:US
Practice Address - Phone:417-926-3937
Practice Address - Fax:417-926-3952
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO91074Medicare PIN
MOU76502Medicare UPIN