MEDICARE: TIFFANY LOUISE MOORE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	15230	CA

General Provider Information

NPI Number	:	1417200288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY LOUISE MOORE O.D.

Provider Business Mailing Address
First Line	:	2024 MONTECITO AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404
Country	:	UM
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 4TH ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4505
Country	:	US
Telephone Number	:	707-542-1554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	06/10/2015

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