Provider Demographics
NPI:1275159873
Name:MOSS, MADISON MCKINNEY (OD)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:MCKINNEY
Last Name:MOSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:ELIZABETH
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 W WEAVER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-6009
Mailing Address - Country:US
Mailing Address - Phone:919-968-6300
Mailing Address - Fax:919-968-0403
Practice Address - Street 1:200 W WEAVER ST STE 1
Practice Address - Street 2:
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-6009
Practice Address - Country:US
Practice Address - Phone:919-968-6300
Practice Address - Fax:919-968-0403
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015993152WC0802X, 152W00000X
NC2647152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management