Provider Demographics
NPI:1083636211
Name:MOSHER, D RUSSELL (PT)
Entity Type:Individual
Prefix:
First Name:D
Middle Name:RUSSELL
Last Name:MOSHER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BULIFANTS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5718
Mailing Address - Country:US
Mailing Address - Phone:757-229-9740
Mailing Address - Fax:757-345-6953
Practice Address - Street 1:109 BULIFANTS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5718
Practice Address - Country:US
Practice Address - Phone:757-229-9740
Practice Address - Fax:757-345-6953
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00637713OtherMEDICARE RR
VAC05304Medicare PIN