MEDICARE: DR. TIMOTHY P MOORE OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1587	GA

General Provider Information

NPI Number	:	1457441453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY P MOORE OD

Provider Business Mailing Address
First Line	:	2658 CAYLOR CIR NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30152-2599
Country	:	US
Telephone Number	:	770-218-3710
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 COBB PKWY S
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-6509
Country	:	US
Telephone Number	:	770-429-9284
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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