Provider Demographics
NPI:1053330860
Name:MOSS, JOAN FISHMAN (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:FISHMAN
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:MARICE
Other - Last Name:FISHMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:310 COMMERCE STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1362
Mailing Address - Country:US
Mailing Address - Phone:714-921-2273
Mailing Address - Fax:
Practice Address - Street 1:310 COMMERCE STE 200
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602
Practice Address - Country:US
Practice Address - Phone:714-921-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA061065207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA061065OtherLICENSE
CA00A610650Medicaid
CA00A610650Medicaid
CAA061065OtherLICENSE