Basic Information
Provider Information | |||||||||
NPI: | 1326079716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFREY L. MORER, OD, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHDRIVE EYE CARE GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 CROSSING BLVD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | FRAMINGHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 017025555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179646681 | ||||||||
FaxNumber: | 3396862561 | ||||||||
Practice Location | |||||||||
Address1: | 200 S EXECUTIVE DR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | BROOKFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 530054216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4145358134 | ||||||||
FaxNumber: | 4145358135 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 01/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORER | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6179646681 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: | 01/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 38713000 | 05 | WI |   | MEDICAID | CN3109 | 01 | WI | MEDICARE RAILROAD | OTHER |