Provider Demographics
NPI:1407906175
Name:MOSBACHER, DIANE BEVERLY (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:BEVERLY
Last Name:MOSBACHER
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 1:1415 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202-4117
Mailing Address - Country:US
Mailing Address - Phone:214-744-2020
Mailing Address - Fax:214-744-0925
Practice Address - Street 1:1415 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-4117
Practice Address - Country:US
Practice Address - Phone:214-744-2020
Practice Address - Fax:214-744-0925
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3369T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093333503Medicaid
TX00E100Medicare ID - Type Unspecified
TX093333501Medicaid