Provider Demographics
NPI:1144511700
Name:MOSS, DAVID R (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1200 RIVERPLACE BLVD
Mailing Address - Street 2:SUITE: 620
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9046
Mailing Address - Country:US
Mailing Address - Phone:904-396-6620
Mailing Address - Fax:904-396-6528
Practice Address - Street 1:1200 RIVERPLACE BLVD
Practice Address - Street 2:SUITE: 620
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9046
Practice Address - Country:US
Practice Address - Phone:904-396-6620
Practice Address - Fax:904-396-6528
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0045122174400000X
FLME451222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6609848OtherAETNA CHOICE POS
FL2164947OtherCIGNA
FL260335700Medicaid
OH27356163700OtherOHIO BUREAU OF WORKERS COMPENSATION
FL694322OtherVALUE OPTIONS
FLN614194OtherWELLCARE
FL694322OtherVALUE OPTIONS