Provider Demographics
NPI:1114584125
Name:MOSS RESTORATIVE FOOT & ANKLE CENTER, PLLC
Entity Type:Organization
Organization Name:MOSS RESTORATIVE FOOT & ANKLE CENTER, PLLC
Other - Org Name:MOSS PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:727-641-2999
Mailing Address - Street 1:PO BOX 40002
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33743-0002
Mailing Address - Country:US
Mailing Address - Phone:727-302-9500
Mailing Address - Fax:727-302-9504
Practice Address - Street 1:7855 38TH AVE N STE 200
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1134
Practice Address - Country:US
Practice Address - Phone:727-302-9500
Practice Address - Fax:727-302-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340659800Medicaid
FL65963OtherBLUE CROSS BLUE SHIELD
T89762OtherUPIN
FL1039020500Medicaid
FL213E00000XOtherTAXONOMY CODE
FL213ES0103XOtherTAXONOMY CODE
FL11429703OtherCAQH