Healthcare Provider Details

I. General information

NPI: 1790800217
Provider Name (Legal Business Name): ROBERT W MOSES OD PROFESSIONAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 DEANNA DR
LOWELL IN
46356-2402
US

IV. Provider business mailing address

117 DEANNA DR
LOWELL IN
46356-2402
US

V. Phone/Fax

Practice location:
  • Phone: 219-696-8077
  • Fax:
Mailing address:
  • Phone: 219-696-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18001579
License Number StateIN

VIII. Authorized Official

Name: DR. ROBERT WILLIAM MOSES
Title or Position: PRESIDENT
Credential: OD
Phone: 219-736-2020