Healthcare Provider Details

I. General information

NPI: 1114035524
Provider Name (Legal Business Name): MEL S MOSS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 N 19TH AVE
PHOENIX AZ
85015-1102
US

IV. Provider business mailing address

10226 E STONEY VISTA DR
SUN LAKES AZ
85248-7643
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-6888
  • Fax: 602-242-4654
Mailing address:
  • Phone: 480-802-4120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number162
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: