Provider Demographics
NPI:1548459498
Name:MOORE, BENJAMIN ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ALAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-1075
Mailing Address - Country:US
Mailing Address - Phone:541-575-1819
Mailing Address - Fax:541-575-0965
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845-1075
Practice Address - Country:US
Practice Address - Phone:541-575-1819
Practice Address - Fax:541-575-0965
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3268ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023687Medicaid
6148680001Medicare NSC