Individual
DR. MARK D MOORE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
504 PETERSON AVE S, DOUGLAS, GA 31533-5254
(912) 389-1230
(912) 389-1260
Mailing address
504 PETERSON AVE S, DOUGLAS, GA 31533-5254
(912) 389-1230
(912) 389-1260
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OPT001723
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
457498953D
—
GA
01
—
GRP7442
MEDICARE PTAN
GA
Enumeration date
08/29/2006
Last updated
03/20/2015
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