Provider Demographics
NPI:1073554747
Name:MOSHER, GARY (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:MOSHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 N WICKHAM RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2369
Mailing Address - Country:US
Mailing Address - Phone:321-254-3042
Mailing Address - Fax:321-254-4770
Practice Address - Street 1:3040 N WICKHAM RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2369
Practice Address - Country:US
Practice Address - Phone:321-254-3042
Practice Address - Fax:321-254-4770
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME488602084P0804X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371572800Medicaid
FL18192OtherBCBSFL
FL18192ZMedicare ID - Type UnspecifiedMEDICARE B
FL371572800Medicaid