Healthcare Provider Details

I. General information

NPI: 1215385364
Provider Name (Legal Business Name): STEPHANIE QUESADA MOORE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2638 JENKS AVE
PANAMA CITY FL
32405-4387
US

IV. Provider business mailing address

802 BEACHCOMBER DR
LYNN HAVEN FL
32444-3420
US

V. Phone/Fax

Practice location:
  • Phone: 850-215-2020
  • Fax: 850-215-2031
Mailing address:
  • Phone: 850-866-8472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC5212
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: