Healthcare Provider Details

I. General information

NPI: 1376511980
Provider Name (Legal Business Name): MARK L MOSTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WALNUT ST STE 930
PHILADELPHIA PA
19107-5109
US

IV. Provider business mailing address

840 WALNUT ST STE 930
PHILADELPHIA PA
19107-5109
US

V. Phone/Fax

Practice location:
  • Phone: 215-928-3130
  • Fax: 215-592-1923
Mailing address:
  • Phone: 215-928-3130
  • Fax: 215-592-1923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD024148E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberMD024148E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: