Provider Demographics
NPI:1770560708
Name:MOORE, MICHAEL D (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:2600 MARTIN WAY E
Mailing Address - Street 2:STE C
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4974
Mailing Address - Country:US
Mailing Address - Phone:360-357-7899
Mailing Address - Fax:360-357-6495
Practice Address - Street 1:2600 MARTIN WAY E
Practice Address - Street 2:STE C
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4974
Practice Address - Country:US
Practice Address - Phone:360-357-7899
Practice Address - Fax:360-357-6495
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0149388OtherL & I
1326213992OtherNPI
WA2631703Medicaid
WA2631703Medicaid
WA0149388OtherL & I
T02763Medicare UPIN
WA001000794Medicare ID - Type Unspecified