Healthcare Provider Details

I. General information

NPI: 1699890111
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: 10/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E 68TH PL
MERRILLVILLE IN
46410-3506
US

IV. Provider business mailing address

70 E 68TH PL
MERRILLVILLE IN
46410-3506
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-2020
  • Fax: 219-769-3884
Mailing address:
  • Phone: 219-736-2020
  • Fax: 219-769-3884

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