=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699979070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAVROULA MOSHOS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 04/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 979 ROUTE 1 SOUTH
-----------------------------------------------------
City | NORTH BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-991-4936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 GRACE RD
-----------------------------------------------------
City | EAST BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08816-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-991-4936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STAVROULA MOSHOS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 732-991-4936
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00603000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------