Provider Demographics
NPI:1376511980
Name:MOSTER, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MOSTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:840 WALNUT ST STE 930
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3130
Mailing Address - Fax:215-592-1923
Practice Address - Street 1:840 WALNUT ST STE 930
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-928-3130
Practice Address - Fax:215-592-1923
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024148E2084N0400X, 207WX0109X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009685800003Medicaid
B37200Medicare UPIN
PA0009685800003Medicaid