Active NPI
Mark Douglas Moore, O. D.
- Optometrist
- Wichita, KS
National Provider Identifier
1346338530
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 1367
- Practice address
- 2020 N Tyler Rd Ste 124
Wichita, KS 67212-4916 - Phone
- (316) 729-0083
- Fax
- (316) 729-0052
- NPI assigned
- Oct 11, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 1367 | KS | Primary |
Addresses
Primary practice location
2020 N Tyler Rd Ste 124
Wichita, KS 67212-4916
Mailing address
2020 N Tyler Rd Ste 124
Wichita, KS 67212-4916
Phone (316) 729-0083
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 049695 | Other | KS | BCBSKS |
| 2531 | Other | KS | PHS/PPK |
| 018096 | Other | KS | BCBSKS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in KS
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050411000690 | KS | Practitioner - Optometry | 3971540071 | Practice locations: Wichita, KS |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1367 | KS | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1160524800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1331164800000",
"number": "1346338530",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2020 N TYLER RD STE 124",
"city": "WICHITA",
"state": "KS",
"postal_code": "672124916",
"telephone_number": "316-729-0083",
"fax_number": "316-729-0052"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2020 N TYLER RD STE 124",
"city": "WICHITA",
"state": "KS",
"postal_code": "672124916",
"telephone_number": "316-729-0083",
"fax_number": "316-729-0052"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOORE",
"first_name": "MARK",
"middle_name": "DOUGLAS",
"name_prefix": "Dr.",
"credential": "O. D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-11",
"last_updated": "2012-03-08",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "KS",
"license": "1367",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBSKS",
"identifier": "049695",
"state": "KS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PHS/PPK",
"identifier": "2531",
"state": "KS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBSKS",
"identifier": "018096",
"state": "KS"
}
],
"endpoints": [],
"other_names": []
}Other providers in Wichita, KS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.