Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | 4579 | SD |
Y | 207W00000X | Ophthalmologist | 4579 | SD |
NPI | 1669470589 |
---|---|
Provider Name | Michael J Moran |
First Address | Watertown, SD 57201-6827 |
Second Address | Watertown, SD 57201-6827 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2005 |
Last Update Date | 24/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
21438 | SIOUX VALLEY HEALTH (01) | |
6301483 | (05) | SD |
G97249 | (02) |