Healthcare Provider Details

I. General information

NPI: 1699979070
Provider Name (Legal Business Name): STAVROULA MOSHOS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 ROUTE 1 SOUTH
NORTH BRUNSWICK NJ
08902
US

IV. Provider business mailing address

5 GRACE RD
EAST BRUNSWICK NJ
08816-2753
US

V. Phone/Fax

Practice location:
  • Phone: 732-991-4936
  • Fax:
Mailing address:
  • Phone: 732-991-4936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00603000
License Number StateNJ

VIII. Authorized Official

Name: DR. STAVROULA MOSHOS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 732-991-4936