Basic Information
| Provider Information | |||||||||
| NPI: | 1730553736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOONAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 691287 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282277022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048930090 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7808 S TRYON ST STE D&E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045228000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1907 | SC | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2444 | NC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.