Provider Demographics
NPI:1477629814
Name:MOSES, MICHAEL JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MOSES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-6362
Mailing Address - Country:US
Mailing Address - Phone:254-780-2663
Mailing Address - Fax:
Practice Address - Street 1:4104 E STAN SCHLUETER LOOP STE 6
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-7873
Practice Address - Country:US
Practice Address - Phone:254-690-8999
Practice Address - Fax:800-710-9601
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4520TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E19VOtherBCBS
TX00E19VOtherBCBS