Healthcare Provider Details

I. General information

NPI: 1548455561
Provider Name (Legal Business Name): GARY M. MOSS, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1769 WASHTENAW RD
YPSILANTI MI
48197-2020
US

IV. Provider business mailing address

1769 WASHTENAW RD
YPSILANTI MI
48197-2020
US

V. Phone/Fax

Practice location:
  • Phone: 734-483-2100
  • Fax: 734-483-2060
Mailing address:
  • Phone: 734-483-2100
  • Fax: 734-483-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4901002648
License Number StateMI

VIII. Authorized Official

Name: DR. GARY M MOSS
Title or Position: OPTOMETRIST/ OWNER
Credential: OD
Phone: 734-483-2100