Healthcare Provider Details

I. General information

NPI: 1669470589
Provider Name (Legal Business Name): MICHAEL J MORAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 14TH AVE NE
WATERTOWN SD
57201-6827
US

IV. Provider business mailing address

705 14TH AVE NE
WATERTOWN SD
57201-6827
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-7722
  • Fax: 605-886-7723
Mailing address:
  • Phone: 605-886-7722
  • Fax: 605-886-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4579
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number4579
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: