Provider Demographics
NPI:1326108747
Name:HERNANDEZ, DIANE MOSSER (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MOSSER
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2408
Mailing Address - Country:US
Mailing Address - Phone:626-359-8145
Mailing Address - Fax:
Practice Address - Street 1:1235 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2408
Practice Address - Country:US
Practice Address - Phone:626-359-8145
Practice Address - Fax:626-359-4116
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08738T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0087381Medicaid
CA1697023Medicaid
CAT70282Medicare UPIN
CASD0087381Medicaid
0641870001Medicare NSC