Provider Demographics
NPI:1093830085
Name:ROBERT W MOSES OD PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:ROBERT W MOSES OD PROFESSIONAL CORP.
Other - Org Name:MOSES EYECARE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-736-2020
Mailing Address - Street 1:701 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1807
Mailing Address - Country:US
Mailing Address - Phone:219-881-0655
Mailing Address - Fax:
Practice Address - Street 1:701 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1807
Practice Address - Country:US
Practice Address - Phone:219-881-0655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001579332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0142650003Medicare NSC