Healthcare Provider Details

I. General information

NPI: 1225338148
Provider Name (Legal Business Name): BRAD MORIARTY OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 MOUNT RUSHMORE RD SUITE 5
RAPID CITY SD
57701-4588
US

IV. Provider business mailing address

1601 MOUNT RUSHMORE RD SUITE 5
RAPID CITY SD
57701-4588
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-4164
  • Fax: 605-348-9773
Mailing address:
  • Phone: 605-343-4164
  • Fax: 605-348-9773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT484
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierS104430
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE PTAN
# 2
Identifier9202310
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: DR. BRAD JEROME MORIARTY
Title or Position: PRESIDENT
Credential: OD
Phone: 605-343-4164