Healthcare Provider Details

I. General information

NPI: 1770783086
Provider Name (Legal Business Name): EMMETT WAYNE MOSLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E COUNTY ROAD 540A
LAKELAND FL
33813-3825
US

IV. Provider business mailing address

1600 LAKELAND HILLS BLVD. CREDENTIALING OFFICE
LAKELAND FL
33805-3019
US

V. Phone/Fax

Practice location:
  • Phone: 863-607-3333
  • Fax: 866-264-8519
Mailing address:
  • Phone: 863-680-7000
  • Fax: 866-264-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberME102864
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME102864
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number26697
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number27540
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number32017
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01075699B
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number048374
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: