Provider Demographics
NPI:1548232432
Name:MOSS, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 NEWCOMB TER
Mailing Address - Street 2:UNIT A
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2220
Mailing Address - Country:US
Mailing Address - Phone:940-224-4228
Mailing Address - Fax:
Practice Address - Street 1:2 NEWCOMB TER
Practice Address - Street 2:UNIT A
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2220
Practice Address - Country:US
Practice Address - Phone:940-224-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0595207L00000X
NY129702207L00000X
CODR-45862207L00000X
MO2012005203207L00000X
NC2007-00793207L00000X
PAMD431239207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114312503Medicaid
C19663Medicare UPIN
TX114312503Medicaid