Provider Demographics
NPI:1073705471
Name:MOSER, KANITA L (OD)
Entity Type:Individual
Prefix:
First Name:KANITA
Middle Name:L
Last Name:MOSER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1818
Mailing Address - Country:US
Mailing Address - Phone:405-632-6688
Mailing Address - Fax:
Practice Address - Street 1:500 SW 44TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3540
Practice Address - Country:US
Practice Address - Phone:405-632-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2509OtherSTATE LICENSE
OK200161980AMedicaid
OK2509OtherSTATE LICENSE