Basic Information
| Provider Information | |||||||||
| NPI: | 1033420575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176983068 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E MECHANIC ST | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620492007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175323036 | ||||||||
| FaxNumber: | 2175326623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046010353 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.