Provider Demographics
NPI:1730177122
Name:MOORE, SCOTT JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JAMES
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 1:1235 S CENTER RD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1235 S CENTER RD
Practice Address - Street 2:SUITE 16
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1700
Practice Address - Country:US
Practice Address - Phone:810-744-1950
Practice Address - Fax:810-744-1515
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02546Medicare UPIN
MIM59350004Medicare ID - Type Unspecified