Provider Demographics
NPI:1457317950
Name:MOSS, GARY M (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:MOSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1769 WASHTENAW RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2020
Mailing Address - Country:US
Mailing Address - Phone:734-483-2100
Mailing Address - Fax:734-483-2060
Practice Address - Street 1:1769 WASHTENAW RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2020
Practice Address - Country:US
Practice Address - Phone:734-483-2100
Practice Address - Fax:734-483-2060
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5069375Medicaid
MI5069375Medicaid
MIU31668Medicare UPIN