Healthcare Provider Details

I. General information

NPI: 1447275557
Provider Name (Legal Business Name): JEFFREY MOORE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 CLEVELAND AVE STE A
FORT MYERS FL
33901-9057
US

IV. Provider business mailing address

5142 SW 3RD AVE
CAPE CORAL FL
33914-7119
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-5393
  • Fax:
Mailing address:
  • Phone: 239-549-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 1680
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: