Healthcare Provider Details

I. General information

NPI: 1245288778
Provider Name (Legal Business Name): MICHAEL D MOSESON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CUTTERMILL RD 507
GREAT NECK NY
11021-3104
US

IV. Provider business mailing address

5 STEPPING STONE CRES
DIX HILLS NY
11746-5011
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-8738
  • Fax: 516-487-1601
Mailing address:
  • Phone: 516-499-6882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number132851
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: