Healthcare Provider Details

I. General information

NPI: 1083277347
Provider Name (Legal Business Name): STEPHANIE QUESADA MOORE OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 12/20/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2638 JENKS AVE
PANAMA CITY FL
32405-4387
US

IV. Provider business mailing address

2638 JENKS AVE
PANAMA CITY FL
32405-4387
US

V. Phone/Fax

Practice location:
  • Phone: 850-215-2020
  • Fax:
Mailing address:
  • Phone: 850-215-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE QUESADA MOORE
Title or Position: OWNER/PROVIDER
Credential: OD
Phone: 850-215-2020