Provider Demographics
NPI:1508870361
Name:MOSS, MARK JEFFREY (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:MOSS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:29701 6 MILE RD
Mailing Address - Street 2:#100A
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-8600
Mailing Address - Country:US
Mailing Address - Phone:734-261-3808
Mailing Address - Fax:734-261-3821
Practice Address - Street 1:29701 6 MILE RD
Practice Address - Street 2:#100A
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-8600
Practice Address - Country:US
Practice Address - Phone:734-261-3808
Practice Address - Fax:734-261-3821
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5901000715213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1352311Medicaid
MI480045246OtherRAILROAD MEDICARE
382334116OtherTAX ID
MI4858254620OtherBLUE CROSS
MI4858254620OtherBLUE CROSS
MI2614Medicare PIN