Provider Demographics
NPI:1760455851
Name:MOORE, DELISHA AMANDA (OD)
Entity type:Individual
Prefix:DR
First Name:DELISHA
Middle Name:AMANDA
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 1:106 LONG CIR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-3138
Mailing Address - Country:US
Mailing Address - Phone:252-537-6101
Mailing Address - Fax:252-537-6103
Practice Address - Street 1:106 LONG CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-3138
Practice Address - Country:US
Practice Address - Phone:252-537-6101
Practice Address - Fax:252-537-6103
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1586152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093HCMedicaid
NC09663OtherBCBSNC
NC89093HCMedicaid
NC09663OtherBCBSNC
NC2469784DMedicare ID - Type Unspecified