Provider Demographics
NPI:1114035524
Name:MOSS, MEL S (OD)
Entity Type:Individual
Prefix:DR
First Name:MEL
Middle Name:S
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 1:10226 E STONEY VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-7643
Mailing Address - Country:US
Mailing Address - Phone:480-802-4120
Mailing Address - Fax:
Practice Address - Street 1:6701 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1102
Practice Address - Country:US
Practice Address - Phone:602-242-6888
Practice Address - Fax:602-242-4654
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ162152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist