Healthcare Provider Details

I. General information

NPI: 1285862490
Provider Name (Legal Business Name): PATRICIA M MOSER OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122-24 BROADVIEW VILLAGE SQUARE
BROADVIEW IL
60155
US

IV. Provider business mailing address

704 KRISTIN CT
WESTMONT IL
60559-3330
US

V. Phone/Fax

Practice location:
  • Phone: 708-343-2099
  • Fax: 708-343-2081
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008530
License Number StateIL

VIII. Authorized Official

Name: DR. PATRICIA M. MOSER
Title or Position: OWNER
Credential: O.D.
Phone: 708034302099