Basic Information
| Provider Information | |||||||||
| NPI: | 1871686758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOREAU | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | 4052713013 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | SUITE B332 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052711096 | ||||||||
| FaxNumber: | 4052716319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0200X | 25055 | OK | Y | 207W00000X | 25055 | OK | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200162200A | 05 | OK | MEDICAID |