Healthcare Provider Details

I. General information

NPI: 1801879028
Provider Name (Legal Business Name): R. LAWRENCE MOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 03/07/2023
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-697-3927
Mailing address:
  • Phone: 904-697-4236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35070198
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberME140171
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: