Provider Demographics
NPI:1679709042
Name:MOORE, ANDREA (OD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
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 1:710 SUPERIOR ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1684
Mailing Address - Country:US
Mailing Address - Phone:208-263-9000
Mailing Address - Fax:208-263-9589
Practice Address - Street 1:710 SUPERIOR ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1684
Practice Address - Country:US
Practice Address - Phone:208-263-9000
Practice Address - Fax:208-263-9589
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist