Healthcare Provider Details

I. General information

NPI: 1225313372
Provider Name (Legal Business Name): TIMOTHY BRIAN MOORE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10627 PROFESSIONAL CIR STE B
RENO NV
89521-5834
US

IV. Provider business mailing address

10627 PROFESSIONAL CIR STE B
RENO NV
89521-5834
US

V. Phone/Fax

Practice location:
  • Phone: 775-507-7171
  • Fax: 775-507-7172
Mailing address:
  • Phone: 775-507-7171
  • Fax: 775-507-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number811
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number811
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number811
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: