Provider Demographics
NPI:1174680987
Name:MOSLEY, FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:MOSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 FARMINGTON AVE
Mailing Address - Street 2:BLDG. F
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4559
Mailing Address - Country:US
Mailing Address - Phone:505-325-1100
Mailing Address - Fax:
Practice Address - Street 1:2700 FARMINGTON AVE
Practice Address - Street 2:BLDG. F
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4559
Practice Address - Country:US
Practice Address - Phone:505-325-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-111302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization