Provider Demographics
NPI:1104846187
Name:MOSS, MARSHALL NORMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:NORMAN
Last Name:MOSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 NE 172ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33162-2639
Mailing Address - Country:US
Mailing Address - Phone:305-654-1121
Mailing Address - Fax:305-940-2065
Practice Address - Street 1:1644 NE 164TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4017
Practice Address - Country:US
Practice Address - Phone:305-940-2065
Practice Address - Fax:305-940-2065
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1170152W00000X, 152WC0802X, 152WL0500X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084858100Medicaid
FL20212Medicare ID - Type UnspecifiedMEDICARE
FL084858100Medicaid